Montgomery General Hospital

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF700May 29, 2025

  Based on observation, record review and staff interview, the facility failed to use appropriate alternatives prior to installing bed rails and failed to assess each resident for the risk of entrapment from bed rails prior to installation. This failed practice was a random opportunity for discovery and had the potential to affect all residents currently residing in the facility during the Long-Term Care Survey Process. Facility Census: 28. Findings Include: a) Facility Bed Rails An observation on 05/29/25 at 10:00 AM, revealed that all empty beds in the Long-Term Care Unit, and all 28 beds currently occupied by a resident had bed rails installed. […]

• No harm, potential for more than minimal, widespreadF851Nov 1, 2023

  Based on observation and staff interview, the facility failed to ensure licensed nurse staffing information based on payroll information was accurately reported to the Centers for Medicare and Medicaid Services (CMS.) This has the potential to affect all residents at the facility. Facility census: 26. Findings included: a) Payroll Based Journal (PBJ) Review of the facility's Payroll Based Journal (PBJ) data from the Certification And Survey Provider Enhanced Reports (CASPER) found the facility did not have licensed nursing coverage 24 hours a day for 51 days during the third quarter of 2023: 04/01/23, 04/02/23, 04/05/23, 04/08/23, 04/09/23, 04/10/23, 04/12/23, 04/13/23, 04/14/23, 04/15/23, 04/16/23, 04/19/23, 04/20/23, 04/21/23, 04/22/23, 04/23/23, 04/26/23, 04/29/23, and 04/30/23. […]

• No harm, potential for more than minimal, patternF880Aug 19, 2026

  Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow proper personal protective equipment (PPE) requirements for a resident on enhanced barrier precautions. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Resident Identifier: #9. Facility Census: 36. […]

• No harm, potential for more than minimal, patternF628May 29, 2025

  Based on record review, and staff interview, the facility failed to notify the Medical Power of Attorney (MPOA) in writing of the transfer to the hospital, and did not provide the bed hold policy for Resident #28. Furthermore, the facility failed to notify the MPOA in writing of the transfer to the hospital, and did not provide the bed hold policy and no notification was sent to the ombudsman for Residents #18, and #10. This failed practice was found true for (3) three of (3) three residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident identifiers #28, #18, and #10. […]

• No harm, potential for more than minimal, patternF812May 29, 2025

  Based on observations and Staff interview the facility failed to ensure foods were probably labelled and discarded when out of date. This failed practice had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 28 Findings include a) On 05/27/25 at approximately 12:00 PM initial tour of the facility kitchen found the following; Two (2) salads were in the walk-in cooler with no dates/labels. One (1) carton of pasteurized eggs in the walk-in cooler with no dated/labels One (1) carton of heavy whipping cream in the walk-in cooler with no dates/labels One (1) carton of cream of wheat in the walk-in cooler with no dates/labels One bag of flour in the dry stock room with no open date One bag of cheesecake mix in dry stock with no open… […]