Montgomery Subacute and Respiratory Center

In the surveyor’s words

From the most serious findings on record at Montgomery Subacute and Respiratory Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Feb 11, 2026

  Based on review of facility policy, observations, record review, and interviews with residents and staff it was determined that the facility did not ensure a safe, clean, comfortable, homelike environment for three of three nursing units reviewed related to the air temperatures. (100 Wing, 200 Wing, 300 Wing)Findings Include: Review of the facility policy titled, Homelike Environment with a revision dated of February 11, 2026 states, Policy Statement- Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy states, 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. […]

• No harm, potential for more than minimal, patternF602Jul 19, 2024

  Based on review of facility policy, review of clinical records and staff interview, it was determined that the facility did not ensure that residents were free of misappropriation of resident property related to diversion of a narcotic medicaton for five of five residents prescribed narcotic medications. (Resident R18, Resident R49, Resident R29, Resident R165, Resident R21) Findings include: Review of facility policy on Abuse, Neglect, Exploitation and Misappropriation Prevention Program revealed that under section Policy Statement, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. […]

• No harm, potential for more than minimal, isolatedF600Aug 11, 2026

  Based on a review of clinical records, review of facility policies, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to protect one resident from verbal abuse for one of 7 residents reviewed (Resident R1). This deficiency was identified as past non-compliance. Findings include: Review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed that Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. […]

• No harm, potential for more than minimal, isolatedF684May 20, 2026

  Based on review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to follow physician' orders related to insulin administration for one of 15 residents reviewed. (Resident R10) Findings include: Review of the facility policy on Insulin Administration dated 2001 revealed that under section PURPOSE: To provide guidance for the safe administration the insulin. Under section PREPARATION: #2 the type of insulin dosage, requirements, strength and method of administration are verified with the order on the medication sheet and the physician's order before administration. Under section GENERAL GUIDELINES: #1 insulin therapies individualized basal prognosis treatment goals and blood glucose levels. […]

• No harm, potential for more than minimal, isolatedF605May 9, 2025

  Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication for two of seven residents reviewed for unnecessary medications (Residents R1, and R47). Findings include: Review of facility policy titled Psychotropic Medication Use (revised 2024), revealed psychotropic medications is any medication that affects brain activity associated with mental processes and behavior. Psychotropic medications are not prescribed or administered on a PRN (as needed) basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days. […]