Montgomeryville Skilled Nursing and Rehabilitati

In the surveyor’s words

From the most serious findings on record at Montgomeryville Skilled Nursing and Rehabilitati, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 23, 2026

  Based on facility policy review, clinical record review, review of facility documentation, observation, and resident representative and staff interviews, it was determined that the facility failed to provide adequate interventions and supervision to prevent elopement (unauthorized departure from the facility) and failed to conduct a thorough investigation for one of 24 sampled residents (Resident 14). This failure resulted in an Immediate Jeopardy situation.Findings include:Review of the facility policy entitled, Elopement of Patients, last reviewed June 12, 2025, revealed that elopement was defined as any situation in which a patient leaves the premises or safe area without the facility's knowledge and supervision. […]

• Actual harm, isolatedF600Jul 14, 2026

  Based on facility policy review, facility documentation review, clinical record review, and staff and resident interviews, the facility failed to ensure that each resident remained free from abuse, resulting in actual physical and psychosocial harm for one of five sampled residents. (Resident 1) Findings include: Review of the undated facility policy entitled, Abuse Prohibition, revealed that the center was to prohibit abuse and mistreatment for all residents. Abuse was defined as willful infliction of injury resulting in physical harm and/or mental anguish. The definition included verbal and physical abuse. The purpose was to ensure that center staff were doing all that was within their control to prevent occurrences of abuse for all residents. […]

• No harm, potential for more than minimal, widespreadF812Jul 23, 2026

  Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department.Findings include: Review of the facility's policy entitled, FBS407 Food Handling, dated May 15, 2026, revealed that foods that were to be prepared and not placed into service were to be covered, labeled, and dated with use by dates. Staff were to check the refrigerator/freezer/dry storage routinely for food items that were expired and discard by the use by date. […]

• No harm, potential for more than minimal, widespreadF812May 22, 2024

  Based on observation and interview, it was determined that the facility failed to store and serve food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen on May 19, 2024, at 9:20 a.m., revealed the following: On a food preparation surface with a microwave, there was an open Pepsi bottle, a staff drink cup, an apron, a mask, crumbs and debris, Styrofoam cups, and plastic lids. The corner of the wall at the entry way was marred and peeling. There was an accumulation of food that remained in the dish machine trap. In an interview, Dietary Aide (DA) 1 stated that the dish machine had not yet been used on that date. […]

• No harm, potential for more than minimal, patternF578Jul 30, 2026

  Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to establish clear advance directives for 5 of 11 sampled residents. (Residents 2, 5, 8, 9, 10)Findings Include: Review of the facility policy entitled, Health Care Decision Making, dated [DATE], revealed that it was the right of all residents to participate in their own health care decision-making, including the right to decide whether they wish to request, accept, refuse, or discontinue treatment, and to formulate or not to formulate an advanced directive. […]