Montgomery Place Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Mar 8, 2023

  The facility reported a census of 28 residents. Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility. Findings included: - An environmental tour of the kitchen, on 03/06/23 at 08:13 AM, noted the following items/areas of concern: 1. Dietary staff CC and DD were preparing and serving breakfast without hairnets on. 2. A resident refrigerator, located inside the kitchen, had a container of potato salad, a container of cole slaw, three containers of cottage cheese and a plate containing a resident's meal, all covered but were unlabeled and lacked a date. 3. […]

• No harm, potential for more than minimal, widespreadF880Mar 8, 2023

  The facility reported a census of 28 with 14 selected for review. Based on observation, interview, and record review, the facility failed to maintain an infection control program to help prevent the development and transmission of infections for two sampled residents including; Resident (R)21's urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) with failure to keep the collection device off of the floor, to decrease the risk of developing a urinary tract infection; and R3 with the failure to ensure staff were managing a nebulizer medication delivery kit in a sanitary manner to decrease the risk of developing a respiratory infection. […]

• No harm, potential for more than minimal, patternF801Feb 6, 2025

  The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for 38 residents who reside in the facility and received their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition. Findings included: - On 02/04/25 at 08:18 AM, observation revealed the kitchen staff finishing the morning meal and preparing the midday meal. Dietary Staff BB stated she was the dietary manager. […]

• No harm, potential for more than minimal, patternF812Feb 6, 2025

  The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to prepare and store food in a sanitary manner for 38 residents who received their meals from the kitchen. This deficient practice placed the residents at risk for foodborne illness. Findings included: - On 02/04/25 at 08:18 AM, during the initial tour of the kitchen, the double-door stainless steel refrigerator had sliced ham stored on a middle shelf with directly above gallons of milk and a large bowl of yellow pudding and unpasteurized eggs also stored on the middle shelf. The fluorescent plastic light cover above the food prep area was cracked through. […]

• No harm, potential for more than minimal, patternF909Mar 8, 2023

  The facility reported a census of 28 residents with 14 selected for review including two residents reviewed for use of side rails, Resident (R)10 and R4. Based on observation, interview, and record review, the facility failed to perform routine inspections of the bed rails to ensure they met safety standards and were not a risk for resident entrapment. The facility reported 17 residents had a rail or other assistive device on the bed. Findings included: - The Medical Diagnosis tab for R10 included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and… […]