Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montgomery General Elderly Care during CMS and state inspections, most recent first.
The facility failed to ensure residents could voice grievances freely without fear of reprisal, as observed during a resident council meeting. Only one resident knew how to file a grievance, while others showed signs of apprehension when asked about fear of retaliation, indicating a potential systemic failure in maintaining a supportive environment for grievance reporting.
The facility failed to provide an environment free from abuse for two residents. One resident with a history of dementia and aggressive behaviors was involved in multiple altercations, and the facility lacked effective interventions. Another resident reported verbal abuse from an LPN, with witness statements confirming inappropriate conduct. The facility's investigation was inconclusive, and policies on abuse and neglect were not effectively implemented.
The facility failed to implement its abuse policy, as evidenced by incidents involving a resident with dementia who exhibited aggressive behaviors and another resident who reported verbal abuse by an LPN. The facility's investigation was incomplete, lacking thoroughness and corrective actions, and the behavioral care plan was not resident-centered.
The facility failed to report and investigate allegations of abuse and neglect involving two residents. One resident experienced discomfort and perceived derogatory comments from staff, while another resident with dementia exhibited aggressive behavior towards others. The facility lacked effective interventions and documentation, and specific policies for dementia care were absent.
The facility failed to thoroughly investigate allegations of verbal and physical abuse involving two residents. One resident reported verbal abuse by an LPN, while another resident with dementia was involved in a physical altercation. The investigations were incomplete, with no corrective actions identified, and the facility lacked specific policies for dementia care and behavioral monitoring.
The facility failed to develop comprehensive care plans for several residents, omitting critical diagnoses such as vascular dementia and COPD. Additionally, care plan interventions were not implemented for two residents, leading to escalated behaviors and risk of pressure ulcers. Staff interviews confirmed these deficiencies, with the administrator acknowledging the issues.
The facility failed to provide appropriate care for two residents. One resident consistently refused medications without physician intervention, despite high blood pressure readings. Another resident, with multiple diagnoses, was not offered hospice services despite end-of-life symptoms. The facility lacked documentation and policies for addressing these issues, as confirmed by the DON.
A facility failed to provide adequate pain management for a resident with multiple diagnoses, including dementia and anxiety. The resident's pain was not properly assessed or documented, and non-pharmacological interventions were not attempted or recorded. Despite a change in medication from Tramadol to Roxanol, the facility did not consistently document pain levels or the effectiveness of the medication, as required by their policy. Interviews revealed that pain was only documented for as-needed medications, not scheduled ones, leading to inadequate monitoring and management of the resident's pain.
The facility failed to maintain accurate and complete records for four residents. A resident's POST form was missing a preparer's signature and date, while another's activity record inaccurately showed participation during active dying. A pneumococcal vaccination was not documented in the electronic medical record, and another resident's POST form lacked a healthcare provider's signature, potentially impacting end-of-life care.
A facility failed to notify the State Ombudsman of a resident's discharge to the hospital. During a survey, it was found that a resident was transferred for an extended hospital stay without the required notification being sent. The LSW admitted to not sending the notification, citing a lack of awareness of the requirement.
A facility failed to update a resident's care plan to include hospice-specific interventions and coordination with the hospice provider. The resident, with severe cognitive impairment and receiving hospice care, had an incomplete care plan lacking guidance on end-of-life needs. The DON acknowledged that hospice details were kept separately and not integrated into the facility's documentation, leading to a risk of inconsistent care delivery.
Failure to Uphold Residents' Grievance Rights
Penalty
Summary
The facility failed to uphold residents' rights to voice grievances freely and without fear of reprisal, as required by CMS standards. During a special resident council meeting, attended by the activities coordinator and a surveyor, residents were asked if they understood how to file an official grievance. Only one resident, identified as the council president, responded, indicating the location of the grievance folder, while other residents remained silent, displaying hesitant or reserved body language. When asked if they feared reprisal for filing grievances, multiple residents showed signs of apprehension, such as crossing arms, nodding affirmatively, or verbally confirming a fear of staff retaliation. This reluctance and collective unease suggest that residents may not feel safe or supported in expressing concerns, potentially undermining the efficacy of the facility's grievance process. The observed discomfort and hesitation to voice concerns indicate a potential systemic failure by the facility to maintain an open, supportive environment for grievance reporting.
Failure to Provide Abuse-Free Environment
Penalty
Summary
The facility failed to provide an environment free from abuse for two residents, as evidenced by multiple incidents involving Resident #158 and Resident #15. Resident #158, who has a history of hallucinations, vascular dementia, Alzheimer's disease, major depressive disorder, delusional disorders, and anxiety, was involved in several physical altercations with other residents. The medical records and nursing notes indicate that Resident #158 exhibited aggressive behaviors, such as hitting, grabbing, and yelling at other residents and staff. Despite these behaviors, the facility did not have specific policies and procedures related to dementia care and behavioral monitoring/interventions, and the interventions documented were ineffective in managing the resident's behaviors. Resident #15 reported verbal abuse from an LPN, who allegedly made derogatory comments about the resident's weight and threatened to send her to another facility. The resident, who has a BIMS score indicating moderate impairment, was visibly upset and emotional distress was noted. Witness statements from staff and the resident's roommate confirmed that the LPN was loud and reprimanding, but the facility's investigation was inconclusive due to a lack of witnesses and evidence. The facility's response to the incident was inadequate, as the resident continued to be upset and the care plan interventions were not followed by the LPN. The facility's investigation into these incidents was found to be lacking, with no thorough or complete corrective action identified. The facility's policies on suspected abuse and neglect were not effectively implemented, as evidenced by the lack of documentation and follow-up on the incidents. The facility's failure to address the residents' behaviors and the staff's inappropriate conduct contributed to an environment that was not free from abuse, neglect, and mistreatment.
Failure to Implement Abuse Policy and Incomplete Investigation
Penalty
Summary
The facility failed to implement its abuse policy and procedure, as evidenced by incidents involving two residents. Resident #158, who has a history of hallucinations, vascular dementia, Alzheimer's disease, major depressive disorder, delusional disorders, and anxiety, was involved in multiple altercations with other residents. Despite being on medications such as Xanax, Lamictal, Zyprexa, and Mirtazapine, Resident #158 exhibited aggressive behaviors, including hitting, grabbing, and yelling at other residents and staff. The facility's documentation showed that interventions were ineffective, and there was no specific policy or procedure related to dementia care and behavioral monitoring/interventions. Another incident involved Resident #15, who reported verbal abuse by an LPN. The resident, who has a BIMS score indicating moderate impairment, claimed that the LPN made derogatory comments about her weight and threatened to send her to another facility. Witness statements from staff and the resident's roommate were inconclusive, and the facility's investigation did not substantiate the allegations. However, the resident remained visibly upset, indicating a failure to address her emotional distress adequately. The facility's investigation into these incidents was found to be incomplete and lacking thoroughness. There were no corrective actions noted in the follow-up of the investigation involving the two residents. The facility's administrator and social worker acknowledged the deficiencies in the investigation process, including the lack of statements from staff or witnesses and the absence of a resident-centered approach in the behavioral care plan.
Failure to Report and Investigate Abuse and Neglect
Penalty
Summary
The facility failed to report all allegations of abuse and neglect to the appropriate state agencies as required. This deficiency was identified during a long-term care survey, affecting two of the four residents reviewed for abuse. One resident expressed discomfort and pain from being left in a wheelchair during mealtime, and a staff member's comment was perceived as derogatory. The facility administrator acknowledged the incident but had not reported it to the state agency until the survey. Another resident, with a history of hallucinations, dementia, and aggressive behavior, was involved in multiple incidents of physical altercations with other residents and staff. Despite these occurrences, the facility's documentation showed that interventions were ineffective, and there was no evidence of a thorough investigation or corrective action. The facility lacked specific policies and procedures for dementia care and behavioral monitoring, which contributed to the ongoing issues with this resident. The facility's failure to report and investigate these incidents thoroughly was further compounded by inadequate documentation and ineffective interventions. The Director of Nursing acknowledged that the interventions were not resident-centered and that the facility did not provide documentation of any effective measures to ensure the safety of other residents. Additionally, an incident on November 8th was not reported or investigated, highlighting a systemic issue in handling and documenting abuse and neglect allegations.
Inadequate Investigation and Behavioral Management in LTC Facility
Penalty
Summary
The facility failed to conduct a thorough and complete investigation regarding allegations of verbal abuse for one resident and physical abuse for another. In the first case, a resident reported verbal abuse by an LPN, who allegedly made derogatory comments about the resident's weight and threatened to send her to another facility. Despite multiple witness statements and the resident's visible distress, the facility's investigation was deemed inconclusive due to a lack of corroborating witnesses and evidence. The LPN was suspended and later returned to work under a Last Chance Agreement, but the investigation did not substantiate the resident's claims. In the second case, a resident with a history of dementia and behavioral disturbances was involved in a physical altercation with another resident, resulting in bruising. The facility's documentation revealed a pattern of aggressive behavior by the resident, including hitting, kicking, and verbal aggression towards staff and other residents. Despite these ongoing issues, the facility lacked specific policies and procedures for dementia care and behavioral monitoring, and the investigation into the incident was incomplete, with no corrective actions identified. The facility's failure to adequately investigate and address these incidents highlights deficiencies in their handling of abuse allegations and behavioral management. The lack of thorough investigations and effective interventions for residents with behavioral issues contributed to the deficiencies identified by the surveyors.
Care Plan Deficiencies and Implementation Failures
Penalty
Summary
The facility failed to develop comprehensive care plans that included all diagnoses for several residents, leading to deficiencies in care. Resident #54's care plan omitted multiple diagnoses, including vascular dementia, pain, shortness of breath, and chronic kidney disease, among others. Similarly, Resident #15's care plan did not include diagnoses such as constipation, hypothyroidism, and COPD. Additionally, Resident #16's care plan was missing diagnoses like heart failure, anemia, and atrial fibrillation. These omissions were confirmed through record reviews and staff interviews, where it was noted that the care plans lacked specific medical terms and descriptions. Furthermore, the facility failed to implement care plan interventions for Resident #15 and Resident #29. For Resident #15, an intervention to maintain a calm environment during behavioral episodes was not followed, resulting in an escalation of the resident's behavior. In the case of Resident #29, the care plan required the resident to wear moon boots at all times to prevent pressure ulcers, but observations revealed that the resident was not wearing them, and staff were unaware of their location. These failures were acknowledged by the facility's administrator and staff during the survey process.
Failure to Provide Appropriate Care and Hospice Services
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents. Resident #23 consistently refused both AM and PM medications from 05/24 to the present, with no physician intervention since 05/24. Despite being educated on the risks of refusing medications, Resident #23 continued to refuse them, and the care plan only included encouragement and masking the taste of medications. The resident's blood pressure was recorded as high 44 times since 06/01/24, yet no further physician intervention was documented. The Assistant Director of Nursing acknowledged the lack of documentation regarding actions taken for the resident's medication refusal. Resident #158 was involved in a physical altercation with another resident, resulting in bruising. The resident had multiple diagnoses, including hallucinations and vascular dementia, and was on a regimen of medications for pain management. Despite the resident's deteriorating condition and the presence of end-of-life symptoms, the facility failed to offer hospice services. The Director of Nursing confirmed that there was no policy or procedure related to hospice services, and the resident was not informed of the available hospice services, nor was there documentation of a care plan addressing end-of-life care. The deficiencies identified in the report highlight the facility's failure to provide appropriate interventions and care planning for residents refusing medications and those requiring end-of-life care. The lack of physician intervention and the absence of hospice service offerings contributed to the deficiencies noted during the survey process.
Inadequate Pain Management and Documentation
Penalty
Summary
The facility failed to provide adequate pain management for a resident, as evidenced by the lack of a formal pain assessment process and a comprehensive, individualized pain management plan. The resident, who had a history of hallucinations, vascular dementia, Alzheimer's disease, major depressive disorder, delusional disorders, and anxiety, was not properly assessed for pain levels despite exhibiting signs of pain such as yelling out, moaning, and facial grimacing. The facility's policy required regular pain assessments and collaboration between the physician, nursing staff, and the resident or their significant others to develop and reassess the pain management plan, which was not adhered to in this case. The resident was initially prescribed Tramadol for pain, which was not effective, leading to a change in medication to Roxanol. Despite this change, the facility did not document the resident's pain levels or the effectiveness of the medication consistently. The resident's care plan included interventions such as administering Roxanol as ordered, documenting its effectiveness, and implementing non-pharmacological measures like gentle rubbing, massage, and repositioning. However, there was no documentation of non-pharmacological interventions being attempted or their effectiveness. Interviews with the Director of Nursing revealed that the facility only documented pain if the resident was receiving as-needed pain medication, not for scheduled medications. This practice led to a lack of documentation and monitoring of the resident's pain levels and the effectiveness of the pain management plan. The deficiency was further highlighted by the absence of documentation of non-pharmacological interventions, which were part of the resident's care plan.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to maintain accurate and complete records for four residents during the survey process. For one resident, the POST form was missing the preparer's signature and date, which was confirmed by the administrator. Another resident's activity participation record inaccurately indicated active participation during a period when the resident was actively dying, a discrepancy that the Activities Director could not explain and was confirmed by the administrator. Additionally, a resident's pneumococcal vaccination was not documented under the immunization tab in the electronic medical record, despite having a signed physician's order and other relevant details recorded elsewhere. The Director of Nursing acknowledged this oversight. Furthermore, another resident's POST form was incomplete, lacking a healthcare provider's signature and date, which was confirmed by the administrator. This incomplete documentation could potentially impact the delivery of end-of-life care for the resident.
Failure to Notify Ombudsman of Hospital Discharge
Penalty
Summary
The facility failed to notify the State Ombudsman of a resident's discharge to the hospital. This deficiency was identified during a Long-Term Care Survey Process, where it was found that one of two residents reviewed for hospitalizations did not have the required notification sent. Specifically, Resident #49 was transferred to the hospital for an extended stay, and upon record review, it was discovered that no notification had been sent to the State Ombudsman. During an interview, the Licensed Social Worker admitted to not sending the notification, stating a lack of awareness of the requirement.
Failure to Integrate Hospice Care into Resident's Care Plan
Penalty
Summary
The facility failed to promptly develop and update a resident's care plan to include hospice-specific interventions and care coordination with the hospice provider. During an annual recertification survey, it was observed that the resident, who was admitted with severe cognitive impairment and was receiving hospice care, had an incomplete care plan. The care plan lacked essential guidance for staff on the resident's end-of-life needs, such as pain management protocols, emotional support resources, and end-of-life preferences. The Director of Nursing acknowledged that hospice coordination details were maintained separately in a binder and not integrated into the facility's care documentation for the resident. The Medication Administration Record (MAR) only included contact information for the hospice provider, without further entries addressing coordinated hospice care. This oversight does not meet the standards established under F657, which require prompt and precise updates to the care plan, creating a risk for inconsistent care delivery and unmet needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Montgomery
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montgomery General Hospital | 0.1 mi | — | 0 | 0 |
| Glasgow Hills Of Journey | 5.4 mi | — | 0 | 0 |
| Ansted Center | 12.9 mi | — | 19 | 0 |
| Marmet Center | 13.1 mi | — | 4 | 0 |
| Fayetteville Healthcare Center | 15 mi | — | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.