Inspection Reports for
Montgomery Nursing and Rehabilitation Center
2817 Albany Post Road, Box 158, Montgomery, NY, 12549
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
120% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 14, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to investigate medication administration errors, medication neglect, and pest control issues at the Montgomery Nursing and Rehabilitation Center.
Complaint Details
The complaint investigation revealed substantiated medication errors including under-dosing and failure to administer medications as ordered, and a significant medication error involving administration of another resident's medications. The pest control complaint was substantiated with evidence of mice presence and inadequate pest control follow-up.
Findings
The facility failed to ensure medication error rates were below 5%, with specific errors in medication administration for residents #34 and #31. A significant medication error occurred when Resident #70 was given medications not prescribed, resulting in chest pain and hospital transfer. Additionally, the facility did not maintain an effective pest control program, with documented evidence of mice presence and inadequate follow-up on pest control measures.
Deficiencies (3)
F 0759: The facility did not ensure medication error rates were below 5%, with errors including under-administration of Tums and failure to administer Vitamin C as ordered.
F 0760: The facility failed to keep residents free from significant medication errors when Resident #70 was given multiple medications not prescribed, causing chest pain and hospital transfer.
F 0925: The facility did not maintain an effective pest control program, failing to document follow-up or monitor the effectiveness of interventions to eradicate mice on one unit and the physical therapy department.
Report Facts
Medication error rate: 5.71
Medication doses administered incorrectly: 2
Medication doses given to wrong resident: 6
Dates of pest control log entries: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #21 | Licensed Practical Nurse | Administered incorrect dose of Tums to Resident #34 |
| Licensed Practical Nurse #20 | Licensed Practical Nurse | Signed off Vitamin C administration that was not given to Resident #31 |
| Licensed Practical Nurse #16 | Licensed Practical Nurse | Self-reported giving wrong medications to Resident #70 and was suspended |
| Director of Nursing | Interviewed regarding medication administration errors and pest control issues | |
| Administrator | Interviewed regarding medication error involving Resident #70 | |
| Physician | Interviewed regarding medication error and resident chest pain | |
| Licensed Practical Nurse Supervisor #21 | Licensed Practical Nurse Supervisor | Supervised medication nurse who gave Resident #70 wrong medications |
| Director of Rehabilitation | Reported mice droppings in physical therapy department | |
| Licensed Practical Nurse #14 | Licensed Practical Nurse | Interviewed about mice sightings and reporting procedures |
| Director of Maintenance/Housekeeping | Interviewed about pest control measures and documentation |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Jan 14, 2025
Visit Reason
The inspection was a recertification survey conducted from January 7, 2025 to January 14, 2025 to assess compliance with regulatory requirements for Montgomery Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including residents' rights to dignity, environmental cleanliness, PASARR screening, care plan implementation, dialysis care, staffing levels, nurse aide performance appraisals, medication administration, food safety, infection control, and pest control.
Deficiencies (11)
F 0550: The facility did not ensure residents' right to dignity; a nurse was observed feeding a resident while standing and a resident's urinary catheter bag was uncovered and visible.
F 0584: The facility did not maintain a clean and homelike environment; floors, radiators, walls, and toilets were dirty or damaged, and meal trays had lime deposit stains.
F 0645: The facility did not ensure thorough completion of PASARR Level 1 Screens prior to admission for 2 of 23 residents reviewed.
F 0656: The facility did not follow the comprehensive person-centered care plan for a resident; bilateral fall mats were not implemented after a fall.
F 0698: The facility did not ensure consistent assessment and communication for a resident receiving dialysis; documentation and communication book sections were incomplete.
F 0725: The facility did not meet minimum staffing requirements for Certified Nurse Aides on 10 of 28 days reviewed.
F 0730: The facility did not complete performance appraisals every 12 months for 5 Certified Nurse Aides reviewed.
F 0759: The facility had a medication error rate of 5.71%; errors included administering incorrect dosage and failure to administer prescribed medication.
F 0812: The facility did not ensure food was stored according to professional standards; multiple food items in refrigerators, freezer, and dry storage lacked labeling, dates, or proper sealing.
F 0880: The facility did not properly implement transmission-based precautions for a resident with Clostridium difficile and failed to maintain an infection surveillance plan for tracking infections.
F 0925: The facility did not maintain an effective pest control program; mice were observed on one unit and in the physical therapy department with no documented follow-up or monitoring of interventions.
Report Facts
Medication error rate: 5.71
Staffing deficiency days: 10
Residents reviewed for PASARR screening: 23
Certified Nurse Aides reviewed for performance appraisals: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #31 | Observed feeding resident while standing | |
| Certified Nurse Assistant #17 | Aware urinary catheter bag was not covered | |
| Director of Nursing | Director of Nursing | Provided statements on dignity, catheter privacy, dialysis communication, infection control, and staffing |
| Certified Nurse Aide #13 | Unaware fall mats were required and not placed | |
| Unit Manager #19 | Supervised staff and provided statements on fall mats and dialysis communication | |
| Licensed Practical Nurse #21 | Administered incorrect medication dosage | |
| Licensed Practical Nurse #20 | Failed to administer Vitamin C and signed off medication incorrectly | |
| Director of Food Services | Director of Food Services | Provided statements on food storage and lime deposits |
| Housekeeper #34 | Did not follow infection control procedures cleaning resident room | |
| Director of Rehabilitation | Reported mice droppings in physical therapy department | |
| Director of Maintenance/Housekeeping | Provided statements on pest control and mouse traps |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 17
Date: Jan 14, 2025
Visit Reason
Multiple standard health and life safety code citations related to quality of care and safety were identified and corrected by March 12-13, 2025.
Findings
Multiple standard health and life safety code citations related to quality of care and safety were identified and corrected by March 12-13, 2025.
Deficiencies (17)
Develop/implement comprehensive care plan
Dialysis
Food procurement,store/prepare/serve-sanitary
Free of medication error rts 5 prcnt or more
Infection prevention & control
Maintains effective pest control program
Nurse aide peform review-12 hr/yr in-service
Pasarr screening for md & id
Resident rights/exercise of rights
Residents are free of significant med errors
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Gas equipment - cylinder and container storag
Smoking regulations
Sprinkler system - maintenance and testing
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Oct 30, 2024
Visit Reason
Standard health citations related to behavioral health services, accident hazards, and quality of care were identified and corrected by December 23, 2024.
Findings
Standard health citations related to behavioral health services, accident hazards, and quality of care were identified and corrected by December 23, 2024.
Deficiencies (3)
Behavioral health services
Free of accident hazards/supervision/devices
Quality of care
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Oct 28, 2024
Visit Reason
The visit was an abbreviated survey conducted to assess compliance with care standards, specifically reviewing treatment, supervision, and behavioral health care for residents.
Findings
The facility failed to ensure that a resident received ordered left hip x-ray after a fall, did not consistently perform 15-minute safety checks as ordered for a resident with suicidal ideation and high fall risk, and did not properly document or communicate these care interventions.
Deficiencies (3)
F 0684: The facility did not ensure a left hip x-ray was performed as ordered after Resident #1's fall on 10/20/24. The order was not communicated to the diagnostic imaging company.
F 0689: The facility failed to provide adequate supervision and consistent 15-minute safety checks for Resident #1, who was at high risk for falls and had suicidal ideation. Documentation of safety checks was incomplete or missing.
F 0740: The facility did not provide necessary behavioral health care for Resident #1 with suicidal ideation. The 15-minute safety checks were not consistently documented or included in care plans, and the reason for discontinuing the order was not documented.
Report Facts
Duration of 15-minute safety checks order: 72
PHQ-9 score: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Named in findings related to failure to order and follow up on left hip x-ray and 15-minute safety checks |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Unable to find left hip x-ray result and responsible for follow-up on orders |
| Director of Nursing | Director of Nursing | Oversight of order entry and follow-up for left hip x-ray and 15-minute safety checks |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding knowledge and performance of 15-minute safety checks |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about performance and documentation of 15-minute safety checks |
| Registered Nurse #2 | Registered Nurse | Interviewed about 15-minute safety checks and documentation |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Spoke with physician to discontinue 15-minute safety checks but failed to document reason |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
One standard health citation for reporting to the national health safety network was identified; deficiency not corrected as of report date.
Findings
One standard health citation for reporting to the national health safety network was identified; deficiency not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 18, 2023
Visit Reason
One standard health citation for reporting to the national health safety network was identified; deficiency not corrected as of report date.
Findings
One standard health citation for reporting to the national health safety network was identified; deficiency not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate compliance with regulations related to resident notification of treatment changes and protection from abuse.
Findings
The facility failed to ensure that a resident's representative was informed in advance of medication changes, specifically an increase in Clonazepam dosage. Additionally, the facility did not protect a resident from physical abuse by a licensed practical nurse, resulting in disciplinary action and increased supervision for the resident.
Deficiencies (2)
F 0552: The facility did not inform Resident #1's representative of the risks, benefits, and alternatives prior to increasing Clonazepam dosage from once to twice daily. The resident was on palliative care and had recent falls and agitation.
F 0600: The facility failed to protect Resident #1 from physical abuse when a Licensed Practical Nurse grasped and pulled the resident by the shirt collar twice while the resident was attempting to self-transfer. The resident was assessed with no injuries but required 1:1 supervision after the incident.
Report Facts
Residents affected: 1
Date of incident: Jun 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in physical abuse finding for grasping and pulling Resident #1 |
| RNUM #1 | Registered Nurse Unit Manager | Interviewed regarding failure to notify resident representative of medication change |
| DON | Director of Nursing | Interviewed regarding notification procedures and abuse incident |
| CNA #1 | Certified Nurse Aide | Witnessed and reported abuse allegation to nursing supervisor |
| RNS | Registered Nursing Supervisor | Assessed resident after abuse allegation and suspended LPN #1 pending investigation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Oct 19, 2023
Visit Reason
Standard health citations related to abuse prevention and resident rights were identified and corrected by December 18, 2023.
Findings
Standard health citations related to abuse prevention and resident rights were identified and corrected by December 18, 2023.
Deficiencies (2)
Free from abuse and neglect
Right to be informed/make treatment decisions
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jul 15, 2022
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for Montgomery Nursing and Rehabilitation Center.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan with measurable goals and interventions to address chewing behaviors for Resident #3. Observations and interviews confirmed the resident exhibited chewing behaviors without an appropriate care plan in place.
Deficiencies (1)
F 0656: The facility did not develop a complete care plan with measurable goals and actions to address chewing behaviors for Resident #3. Observations and record reviews confirmed the absence of a behavior care plan despite documented chewing behaviors.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA #1) | Interviewed regarding Resident #3's chewing behavior and towel use. | |
| Licensed Practical Nurse (LPN #1) | Interviewed about Resident #3's chewing behavior and care plan responsibilities. | |
| Registered Nurse Unit Manager (RNUM) | Interviewed about the absence of a behavior care plan for Resident #3 and responsibility for care plans. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Jul 15, 2022
Visit Reason
Standard health and life safety code citations related to care planning and fire safety were identified and corrected by September 2022.
Findings
Standard health and life safety code citations related to care planning and fire safety were identified and corrected by September 2022.
Deficiencies (3)
Develop/implement comprehensive care plan
Illumination of means of egress
Portable fire extinguishers
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jul 30, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including environmental cleanliness, failure to notify residents' representatives in writing about transfers and bed hold policies, incomplete care plans for residents, expired medications, lack of carbon monoxide detectors in mechanical rooms, and inadequate infection prevention practices.
Deficiencies (9)
F 0584: The facility did not maintain a clean environment; floors, doors, baseboard trims, and ceiling tiles were stained or dirty in multiple resident rooms and common areas.
F 0623: The facility failed to provide timely written notification to residents' representatives regarding hospital transfers for 3 residents reviewed.
F 0625: The facility did not notify the resident or representative in writing about the bed hold policy for 1 resident reviewed.
F 0656: The facility failed to develop and implement complete care plans addressing cellulitis and wounds for 2 residents reviewed.
F 0657: The facility did not revise comprehensive care plans within 7 days to address changes in skin condition and hearing ability for 2 residents.
F 0685: The facility did not ensure residents received proper treatment and assistive devices to maintain hearing ability; one resident's hearing aid was lost and not replaced.
F 0755: Expired medications were found on medication carts and in medication rooms, including insulin and warfarin for a resident on anticoagulation therapy.
F 0836: The facility lacked carbon monoxide detectors in mechanical rooms housing fuel-fired equipment as required by fire code.
F 0880: The facility failed to implement infection prevention practices; a resident's foley catheter tubing was observed dragging on the floor during therapy sessions.
Report Facts
Residents reviewed for hospitalization notification: 3
Residents sampled for care plan deficiencies: 22
Expired medications found: 1
Expired warfarin tablets: 28
Expired insulin bottles: 5
Expired Neupogen vials: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse, Unit Manager | Interviewed regarding lack of written notification of transfers and care plan deficiencies |
| Social Worker | Interviewed regarding lack of written notification of transfers and bed hold policy | |
| Maintenance Director | Confirmed environmental cleanliness deficiencies and plans for repairs | |
| Medication Nurse #1 | Unaware of expired medications in medication cart | |
| Medication Nurse #2 | Interviewed about expired medications and medication room inspections | |
| Unit Supervisor #1 | Confirmed nurses' responsibility for checking expired medications | |
| Director of Nursing | Confirmed no follow-up on missing hearing aid since 2017 | |
| Physical Therapist | Observed foley catheter tubing on floor and confirmed it should not touch floor | |
| Therapy Director | Confirmed foley catheter tubing was on floor |
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