Montgomery Place

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 31, 2026

  Based on interviews and record reviews, the facility failed to assess one [R1] resident risk of an accident, identify, implement interventions measures to reduce the hazards or risk as much as possible consistent with R1's needs, goals, care plans and current professional standards of practice to reduce the risk of an accident out of four residents reviewed.These failures resulted in R1 sustaining a right elbow dislocation with mildly displaced fracture of the tip of the coronoid and olecranon process from an unknown origin. Findings Include R1's clinical record indicates the following in part. […]

• Actual harm, isolatedF600Jul 11, 2026

  Based on observations, interviews, and record review, the facility failed to protect a resident's right to be free from physical abuse by a staff member and failed to immediately report an allegation of abuse to the designated abuse coordinator. As a result, Resident (R1) remained fearful, and the alleged perpetrator continued to be assigned to provide care after the allegation was reported to the nurse. The failure to promptly report the allegation had the potential to delay the investigation and place residents at risk for further abuse. This deficient practice affected one (R1) of three residents reviewed for abuse. Findings include:R1 had diagnoses including dementia, mood disorder, chronic pain, seizures, and other chronic conditions. […]

• Actual harm, isolatedF689Feb 15, 2026

  Based on interview and record review, the facility failed to maintain resident safety during a mechanical sit to stand lift transfer and failed to use a two person assist when transferring a dependent resident at high fall risk for one (R1) of three reviewed for safety and mechanical lift transfer. This failure resulted in R1 sustaining a right femoral fracture.Findings Include:R1 is a [AGE] year-old initially admitted to the facility on [DATE] with a diagnosis of fractured tibia/fibula after sustaining a fall. […]

• Actual harm, isolatedF684Jun 16, 2023

  Based on interview and record review, the facility failed to provide R2 with the correct medication at discharge. This failure resulted in R2 being discharged with another resident's medication, ingesting the incorrect medication, resulting in urinary retention and hospitalization for urinary catheterization. This affected one(R2) of three residents reviewed for discharge. Findings Include: Facility Final Investigation Report (dated 06/01/2023) regarding R2 documents in part: R2 was admitted to facility on April 27, 2023, for short-term rehabilitation, and was discharged on [DATE]. He was alert and oriented x4. R2 had teaching completed upon discharge by agency nurse, patient verbalized understanding. […]

• Actual harm, isolatedF686Aug 24, 2022

  Based on observations, interviews and record reviews, the facility failed to provide the necessary treatment and services to promote healing and prevent infection from developing for 2 (R1 and R2) of 3 residents reviewed for wounds. These failures resulted in a clinical wound status change for R2's sacral wound in which facility staff noted the wound with drainage and a foul odor. The emergency room records document in part that R2's sacral wound with pus drainage and the likely source of [CONDITION(S)]. Findings include: R1's face sheet documents in part admitted [DATE]. It does not document in part any diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor reviewed R1's progress notes from admission. […]