Montgomery Senior Living

The facility failed to ensure the special care unit (SCU) was free from chronic unpleasant odors. Surveyors observed strong urine odors in the SCU hallways, common areas, resident rooms, and shared bathrooms. Additionally, a toilet in a resident bathroom was found with old dried feces and urine and was non-functional.

The facility failed to ensure the special care unit (SCU) was free from chronic unpleasant odors. Observations revealed strong urine odors in hallways, common areas, resident rooms, and shared bathrooms. Interviews with staff and the administrator confirmed the odor had been present for some time and was linked to plumbing issues and past resident behaviors.

The facility failed to ensure the Special Care Unit (SCU) was free of chronic urine odors in the hallways, resident rooms, and resident bathrooms. Observations and staff interviews confirmed strong urine odors persisted in multiple areas for several years. Staff noted that inadequate housekeeping hours and insufficient cleaning products contributed to the issue.

The facility failed to administer medications as ordered by a physician for one resident. Specifically, the resident continued to receive a 10mg dose of Amlodipine Besylate on 06/01/22 despite a new physician order dated 06/01/22 to decrease the dosage to 5mg. The medication aide failed to verify the directions on the medication card, relying instead on the assumption that the electronic system would alert them to dosage errors.

The facility failed to administer medications as ordered by a physician for one resident. Specifically, a medication for hypertension (Amlodipine Besylate) was not updated in the medication cart following a change in dosage orders. Staff failed to verify the medication card directions and did not ensure the correct dosage was available in the cart.

The facility failed to ensure that one of five sampled residents was tested for tuberculosis disease upon admission. Specifically, there was no documentation of a TB skin test or chest x-ray performed at the time of the resident's admission on 08/07/19.

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The facility failed to ensure that one of five sampled residents was tested for tuberculosis disease upon admission. Records showed no documentation of a TB skin test or chest x-ray for Resident #1 following their admission from a local hospital.

The facility failed to ensure that care plans were developed for two of six sampled residents within 30 days following admission. Specifically, the facility could not demonstrate timely care plan completion for Residents #1 and #3 in conjunction with their resident assessments.

The facility failed to ensure that housekeeping storage areas containing hazardous cleaning agents were locked and inaccessible to residents on the Special Care Unit. An unlocked closet with a keyed knob was observed, and staff were not present to monitor the area during the time a resident was in the hallway.

The facility failed to ensure that a resident's prescribed renal therapeutic diet was served as ordered by the physician. Specifically, the facility failed to provide the required protein, rice/noodle, and beverage components of the ordered diet during a lunch meal observation.