Montgomery Nursing & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Montgomery Nursing & Rehab CTR, in the surveyor’s own words.

• Actual harm, isolatedF689May 23, 2024

  Based on observation, interview, and record review the facility failed to adequately supervise 1 of 1 resident (R5), reviewed for accidents and incidents, in a sample of 5. This failure resulted in R5 spilling coffee on herself and sustaining second degree burns. This past non-compliance occurred between 4/28/24 and 4/30/24. Findings Include: Facility reported incident, dated 4/30/2024, documented, [AGE] year-old female with Dementia, Atrial Fibrillation, Hypertension, Anxiety, Severely Cognitively Impaired. On 4/28/2024 at 10:16AM R5 was in room with breakfast tray. R5 attempted to stand and used the bedside table to stand up and the coffee that was on the breakfast tray spilled onto R5's lap. R5 was immediately assessed and R5 noted to have redness to right upper thigh. […]

• Actual harm, isolatedF580Feb 15, 2023

  Based on interview and record review, the Facility failed to notify the Physician/Nurse Practitioner (NP) of all pertinent information regarding a resident's change in condition for one of one resident (R324) reviewed for physician notification in the sample of 31. This resulted in R324 having a delay in treatment for a change in neurological condition. Findings include: R324's Face Sheet, undated, documents R324 had the following diagnoses: Type 2 DM (Diabetes Mellitus), CHF (Congested Heart Failure), Obesity, Major Depressive Disorder, Anxiety Disorder, HTN (Hypertension), ASHD (Atherosclerotic Heart Disease), GERD (Gastric Esophageal Reflux Disease), Neuropathies, Osteoarthritis, Asthma, Hyperlipidemia, Disease of Liver, Chronic Pain, Unspecified Kidney Failure, COVID-19. […]

• Actual harm, isolatedF684Feb 15, 2023

  Based on interview and record review, the facility failed to recognize a change in neurological condition, notify the physician/nurse practitioner (NP) of all pertinent information, and provide service to address changes in condition for one of one resident (R324) reviewed for quality of care in the sample of 31. This resulted in R324 having a delay in treatment for a change in neurological condition. Findings include: R324's Face Sheet, undated, documents R324 was admitted on [DATE], and was discharged on [DATE]. […]

• No harm, potential for more than minimal, widespreadF761Mar 27, 2025

  Based on observation, interview, and record review, the facility failed to properly store medication and label multi dose insulin vials and pens. This has the potential to effect all residents residing in the facility. Findings include: On 3/24/2025 at 11:12 AM the facility's 500 Hall Medication Cart was inspected. The medication cart contained the following: 1. An opened and unlabeled multi dose Lispro insulin vial. The multi-dose vial did not have a resident identifier or open date. On 3/24/2025 at 11:13 AM V20, Licensed Practical Nurse (LPN), verified that the vial was open, partially used, undated and not labeled. V20 stated that the vial should be labeled with the resident's name and open date. V20 stated that the vial belonged to R31. […]

• No harm, potential for more than minimal, widespreadF761Mar 13, 2024

  Based on observation, interview and record review, the facility failed to discard insulin pens after being in use for longer than 28 days, remove and dispose of expired medications, and not store food items in the medication refrigerator. This failure has the potential to affect all 75 residents residing in the Facility. Findings include: On 03/10/24 at 8:40 AM, The front medication room was inspected. The unlocked refrigerator, in the medication room contained the following: 1. There was a container of personal food and a 2% milk. 2. An unopened box of Tylenol suppository's 650mg (milligrams) with an expiration date of 12/2023. 3. R68's opened Lansprazole suspension 3mg/ml (milligrams/milliliter) with no open date or discard noted to the bottle. […]