Montgomery Nursing And Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600Jul 28, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF812Jul 28, 2026

  Based 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.The findings include:The undated Policy for maintenance work order reporting documented that all facility maintenance concerns shall be reported using the electronic work order system. […]

• No harm, potential for more than minimal, patternF584Jan 14, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF725Jan 14, 2025

  Based 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. The findings are: The Facility Assessment Staffing Plan Minimum Staffing documented Day shift: 3 Licensed Nurses on both units and 3 Nurse Aides on both units. Evening shift: 2 Licensed Nurses on both units and 3 Nurse Aides on both units. Night shift: 1 Licensed Nurse on both units and 2 Nurse Aides on both units. […]

• No harm, potential for more than minimal, patternF730Jan 14, 2025

  Based 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. The findings are: There was no documented evidence that performance appraisals were completed every 12 months for Certified Nurse Aide #1, #2, #3, #4 and #5. During an interview on 1/08/25 at 9:25 AM the Director of Nursing stated they were aware that performance appraisals should be completed for the Certified Nurse Aides and stated they were responsible for writing the performance appraisals. 10 NYCRR 415.12(h)(1)