Montgomery Village Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF558Apr 16, 2025

  Based on observations and staff interviews, it was determined that the facility failed to ensure that call bells were kept within reach for residents to utilize. This was found to be evident for 8 (Residents #3, #23, #45, #49, #53, #73, #99, and #105) of 44 residents observed on the 4th floor of the facility during the recertification survey. The findings include: During observations of the 4th floor of the facility during the morning on 4/3/2025, the surveyor observed call bells on the floor and not within reach of Residents #3, #23, #49, #53, #73, #99, and #105. Further observations by surveyor on 4/4/2025 revealed the call bell on the floor for Resident #45 and call bells on the floor and not accessible for Residents #3, #49, and #73. […]

• No harm, potential for more than minimal, isolatedF551Jun 5, 2026

  Based on record review, and staff interviews, it was determined that the facility failed to properly identify, verify, and document a legally authorized resident representative to exercise the rights of a resident who lacks capacity. This deficient practice was evident for 2 (Resident #8 and Resident #71) of 2 residents reviewed for rights exercised by representative during the annual survey. The findings include: The BIMS score, short for Brief Interview for Mental Status, comes from a quick test that looks at how well you think, learn and remember. Scores range from 0 to 15. […]

• No harm, potential for more than minimal, isolatedF552Jun 5, 2026

  Based on record review and staff interviews, it was determined the facility failed to ensure consent for psychotropic medications was obtained and maintained in accordance with resident decision-making capacity. This deficient practice was evident for 4 (Resident #4, Resident #5, Resident #3, Resident#8) of 5 residents reviewed for psychotropic medication consent during the annual survey.The findings include:Psychotropic medication is any drug that affects brain activities associated with mental processes and behavior.1.) On 06/03/2025 at 7:45 AM, a review of Resident #4's medical record revealed that on 11/30/2022, and 12/05/2022, two physicians certified the resident lacked decision-making capacity due to dementia and delirium. […]

• No harm, potential for more than minimal, isolatedF578Jun 5, 2026

  Based on record review and staff interviews, it was determined that facility staff failed to properly manage care choices for residents in the absence of an advance directive. This deficient practice was evident for 2 (Resident #16 and Resident #4) of 7 residents reviewed for Advance Directives during the annual survey. The findings include: 1.) On 06/02/2026 at 8:24 AM, a review of Resident #16's medical records revealed the resident was admitted to the facility in February 2025 with multiple medical diagnoses including dementia. At the time of admission, the resident was screened for Advance Directive (AD). Records revealed that an AD form was reviewed with the resident, and a copy was provided; however, the resident declined to formulate an AD. […]

• No harm, potential for more than minimal, isolatedF584Jun 5, 2026

  Based on observation and interviews with facility staff, it was determined that the facility failed to ensure that the environment of resident's care area was kept safe and sanitary. This was evidenced by the paper towel dispenser missing the front cover, which exposed paper towels in the bathroom. This was evident for 2 (Resident #9 and Resident #14) of 160 residents observed during the annual survey. The findings include: On 06/01/2026 at 11:10 AM, during the initial observation of room [ROOM NUMBER] for Resident #9 and #14's bathroom, the front cover of the paper towel dispenser was missing, exposing brown paper towels. […]