Montgomery Care Center

In the surveyor’s words

From the most serious findings on record at Montgomery Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 1, 2021

  Based on review of closed medical record, interviews with facility staff and the Coroner office investigator, review of Emergency Medical Service (EMS) run report, review of hospital records, review of Coroner's report, review of the facility investigation and review of information from the National Dysphagia Diet, the facility failed to provide adequate supervision for a cognitively impaired resident with [DIAGNOSES REDACTED]. [REDACTED]. This resulted in Immediate Jeopardy and serious life-threatening consequences when Resident #06 collapsed in the hallway, with food in his mouth, and subsequently choked and died . This affected one (#06) of four residents sampled for supervision with meals. […]

• No harm, potential for more than minimal, widespreadF812Mar 2, 2022

  Based on observation, staff interviews, record review, and review of the facility policies, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. This had the potential to affect 69 of 70 residents residing in the facility, excluding Resident #50 who received enteral feedings and nothing by mouth. Findings include: 1. An initial tour of the kitchen was conducted on 02/14/22 at 9:45 A.M. with Cook #22. While touring the kitchen, the following was observed: 1a. The free-standing walk-in freezer located outside of the building with Cook #22 felt very warm and observation revealed a non-functioning thermometer sitting on the shelf. […]

• No harm, potential for more than minimal, widespreadF880Oct 27, 2021

  Based on observation, interview, and policy review, the facility failed to ensure staff changed gloves and performed hand hygiene as appropriate to prevent the spread of infection. This affected seven (Residents #17, #18, #20, #47, #49, #57 and #58) and had the potential to affect all residents in the facility. The facility census was 69. Findings include: 1. During observation on 10/26/2021 at 9:20 A.M., Activities Aide (AA) #5 wore gloves as she pushed a beverage cart into the dining room to serve coffee to residents. AA #5 poured coffee, removed her jacket, and served coffee to Resident #20. She then prepared a cup of hot chocolate and served it to Resident #49. […]

• No harm, potential for more than minimal, widespreadF802Sep 9, 2021

  Based on observation, record review and interview, the facility failed to employ and provide dietary staff persons in sufficient number to carry out the functions of the food and nutrition services department in a timely manner, and consistent with the planned menu. This had the potential to affect all 70 residents of the facility. Findings include: 1. Interview with the facility's consultant Registered Dietitian (RD) #78 on 08/30/21 at 3;21 P.M. revealed the Dietary Manager (DM) #72 in the kitchen was new, and had been here about three or so months. […]

• No harm, potential for more than minimal, widespreadF812Sep 9, 2021

  Based on observation, staff interview and policy review, the facility failed to store and prepare food in accordance with accepted food safety standards in order to prevent the potential spread of foodborne illness. This had the potential to affect all 70 residents of the facility. The facility census was 70. Findings include: Meal preparation and service was observed for the evening meal on 08/30/21 beginning at 3:47 P.M. through 6:35 P.M. During tour of the central kitchen and observation of meal preparation and service the following was observed: a) In the walk-in refrigerator there were four 46 ounces cartons of thickened liquids that were opened, and undated as to when they were opened. […]