MONTGOMERY GENERAL HOSPITAL
Non profit - Corporation
44 Beds
Independent
Data: November 2025
Trust Grade
50/100
#77 of 122 in WV
Photo by Timothy Scott
Photo by Timothy Scott
Photo by Tim Scott
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Montgomery General Hospital has a Trust Grade of C, which means it is average compared to other nursing homes-neither particularly good nor bad. It ranks #77 out of 122 facilities in West Virginia, placing it in the bottom half, and #4 out of 6 in Fayette County, indicating that there are only three other options available locally. The facility appears to be improving, as the number of issues reported decreased from 17 in 2023 to 13 in 2025. Staffing is stable, with a 0% turnover rate, which is excellent compared to the state average of 44%. However, there are some concerns: the facility has had issues with bed rail safety assessments and failed to notify family members regarding hospital transfers for residents, which could potentially impact their well-being. Overall, while there are strengths in staffing and an improving trend, families should be aware of these significant shortcomings as they consider this facility.
- Trust Score
- C
- In West Virginia
- #77/122
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ✓ Good
- Each resident gets 52 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 39 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 37%
No red flags
17 → 13 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 17 issues
2025: 13 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below West Virginia average (2.7)
Below average - review inspection findings carefully
The Ugly 39 deficiencies on record
May 2025
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and Staff interview the facility failed to ensure residents who room together were served lunch in a dignified manner, by not surveying meals at the same time. This was a random o...
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Based on observation and Staff interview the facility failed to ensure residents who room together were served lunch in a dignified manner, by not surveying meals at the same time. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Resident identifier: #2, #20 Facility Census: 28
Findings include:
a) An observation during lunch tray pass on the hall on 05/28/25 at 4:21 PM revealed Resident #2 was served and had half his food eaten before Resident #20 was served. The residents were served approximately 15 minutes apart.
During an interview on 05/28/25 with the Director of Nursing (DON) the DON stated, He (resident #20) gets his tray later because he requires staff to assist them. Confirming Resident #20 was not served and assisted when Resident #2 was given their lunch tray.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to ensure privacy and confidentially during medication administration. Facility Census: 28.
Findings Include:
a) Computer on the Medicatio...
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Based on observation and staff interview, the facility failed to ensure privacy and confidentially during medication administration. Facility Census: 28.
Findings Include:
a) Computer on the Medication Cart
On 05/28/25 at 4:34 PM, an observation of the medication cart sitting in the corridor by the elevators was unlocked and the computer screen was left unlocked. Licensed Practical Nurse (LPN) #34 was sitting in the employee lounge. There was no line of sight between LPN #34 and the medication cart. LPN #34 stated, I was just getting a drink.
On 05/28/25 at 4:36 PM, the Director of Nursing (DON) was notified and stated, the medication cart and the computer should be locked.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on Record review and staff interview the facility failed to provide an accurate MDS diagnosis of Parkinsonism. This was found to be true for one (1) of 15 residents whose Minimum Data Set (MDS) ...
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Based on Record review and staff interview the facility failed to provide an accurate MDS diagnosis of Parkinsonism. This was found to be true for one (1) of 15 residents whose Minimum Data Set (MDS) was reviewed during the Long Term-Care Survey Process. Resident Identifier: #23 Facility census:28
Findings include:
a) Resident #23
Record review completed on 05/27/25 03:42 PM revealed the following diagnosis
Parkinsonism, unspecified
Further record review of a consultation record completed by a neurologist on 12/14/23 revealed the neurologist had diagnosed Resident #23 to have Parkinsonism.
Review of Resident #23's MDS section I (Active Diagnoses) that was completed on 03/14/24 revealed under the Neurological section that Parkinsonism was not marked.
On 05/28/25 at 03:56 PM The Director of Nursing (DON) confirmed Parkinsonism was not identified in the MDS Completed on 3/14/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to provide an accurate Pre-admission Screening and Resident Review (PASARR) containing all diagnoses for Resident #22 and #23. Resident ...
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Based on record review and staff interview, the facility failed to provide an accurate Pre-admission Screening and Resident Review (PASARR) containing all diagnoses for Resident #22 and #23. Resident identifiers: #22 and #23. Facility Census: 28.
Findings include:
a) Resident #22
On 05/27/25 at 3:17 PM, a record review was completed for Resident #22. The review found the PASARR dated 03/09/25 did not contain three (3) diagnoses. The following diagnoses were not included: Unspecified dementia, mild with anxiety, Bipolar disorder, in partial remission, most recent episode depressed and Depression, unspecified.
On 05/28/25 at 3:06 PM, an interview was held with the Social Services Director (SSD). The SSD stated, thank you for letting me know.
b) Resident #23
Review of PASARR on 05/27/25 at 1:42 PM revealed Bipolar disorder, Major depressive disorder was marked on the PASARR
Further record review revealed the following Diagnoses:
G20.C Parkinsonism, unspecified
R45.851 Suicidal ideations (History of)
F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features
05/28/25 2:56 PM DON confirmed Parkinsonism was not identified in the PASARR and Major Depressive disorder was identified on the PASARR when Resident #23 had no active diagnosis for Major Depressive Disorder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review, staff interview, and resident interview the facility failed to develop or implement a care plan related to nutrition and diagnoses. This failed practice was found true for toe ...
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Based on record review, staff interview, and resident interview the facility failed to develop or implement a care plan related to nutrition and diagnoses. This failed practice was found true for toe (2) of 15 residents whose care plan were reviewed during the Long Term-Care Survey process. Resident identifiers: #23 and #26. Facility census: 28
Findings include:
a) Resident #23
On 05/27/25 at 03:42 PM the following diagnoses was reviewed in Resident #23's medical record:
Parkinsonism, unspecified
Suicidal ideations (History of) Not marked on PASSR
Further Record review of Resident #23's care plan showed neither diagnosis was identified in the resident person-centered care plan.
05/28/25 03:56 PM DON confirmed Parkinsonism and History of Suicidal Ideations was not identified in Resident #23's care plan.
b) Resident #26
On 05/27/25 at 4:34 PM, an interview was held via telephone with Resident #26's representative. The representative stated, She is not eating well .I'm concerned. She dislikes eggs.
On 05/28/25 at 7:56 PM, a record review was completed for Resident #26. The review found the care plan was not implemented under the focus area of potential for altered nutrition r/t (related to) no concentrated sweets diet. An intervention for the area of altered nutrition was for the facility to assess the residents likes/dislikes and provide diet as ordered with as many of resident's desired food choices.
On 05/29/25 at 9:05 AM, an interview was held with the Director of Nursing (DON). The DON was asked, Will you provide a list of food likes/dislikes? The DON stated, We don't have the food likes and dislikes .the dietary manager does that with the nursing home next door .if someone doesn't like something we usually find out over time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to maintain the environment of which it had control over to remain free of accident hazards due to the medication cart being unlocked. Fac...
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Based on observation and staff interview, the facility failed to maintain the environment of which it had control over to remain free of accident hazards due to the medication cart being unlocked. Facility Census: 28.
Findings Include:
a) Medication Cart
On 05/28/25 at 4:34 PM, an observation of the medication cart sitting in the corridor by the elevators was unlocked and the computer screen was left unlocked. Licensed Practical Nurse (LPN) #34 was sitting in the employee lounge. There was no line of sight between LPN #34 and the medication cart. LPN #34 stated, I was just getting a drink.
On 05/28/25 at 4:36 PM, the Director of Nursing (DON) was notified and stated, The medication cart and the computer should be locked.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review, resident representative interview and staff interview, the facility failed to document all meal intake percentages for Resident #26, who was identified with weight loss. This w...
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Based on record review, resident representative interview and staff interview, the facility failed to document all meal intake percentages for Resident #26, who was identified with weight loss. This was true for one (1) of two (2) residents reviewed under the care area of nutrition. Resident identifier: #26. Facility Census: 28.
Findings Include:
a) Resident 26
On 05/27/25 at 4:34 PM, an interview was held via telephone with Resident #26's representative. The representative stated, She is not eating well .I'm concerned. She dislikes eggs.
On 05/28/25 at 7:56 PM, a record review was completed for Resident #26. The review of meal percentages from 04/08/25 through 05/28/25 found no documentation for the following dates:
--04/17/25 dinner
--04/19/25 dinner
--04/20/25 breakfast
--04/20/25 lunch
--04/20/25 dinner
--04/28/25 lunch
--05/06/25 dinner
A further review of the resident's weights found a 5.1% of weight loss from 04/08/25 through 05/08/25. The following is a list of the resident's weights:
--04/08/25 163.60
--04/10/25 162.70
--04/17/25 159.00
--04/24/25 157.40
--05/01/25 157.80
--05/04/25 156.80
--05/08/25 155.30
No documentation from the facility physician or the registered dietician was found.
On 05/29/25 at 9:05 AM, the Director of Nursing (DON) was notified of the weight loss of 5.1%. The DON stated, We don't have the food likes and dislikes .the dietary manager does that with the nursing home next door .if someone doesn't like something we usually find out over time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview, the facility failed to offer a pneumococcal vaccination to Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview, the facility failed to offer a pneumococcal vaccination to Resident #18. This was true for one (1) of five (5) residents reviewed under the care area of infection control. Resident Identifier: #18. Facility Census: 28.
Findings Include:
a) Resident #18
On 05/27/25 at 1:30 PM, Resident #18 asked, are you here to bring me my pneumonia shot? The resident was admitted to the facility on [DATE] and no documentation was found listing any immunizations the resident had received.
On 05/29/25 at 11:25 AM, the Director of Nursing (DON) was interviewed regarding the pneumococcal vaccination for Resident #18. The DON stated, we have ordered them .but they haven't came in yet .the resident was not offered a pneumococcal vaccination since she has been here.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to notify the Medical Power of Attorney (MPOA) in writing of th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to notify the Medical Power of Attorney (MPOA) in writing of the transfer to the hospital, and did not provide the bed hold policy for Resident #28. Furthermore, the facility failed to notify the MPOA in writing of the transfer to the hospital, and did not provide the bed hold policy and no notification was sent to the ombudsman for Residents #18, and #10. This failed practice was found true for (3) three of (3) three residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident identifiers #28, #18, and #10. Facility census: 28.
Findings include:
a) Resident #28
A record review, on 05/29/25 at 12:00 PM, revealed that Resident #28 had been transferred to the hospital on [DATE].
Further record review found no transfer/discharge notifications, or the bed hold policy was sent to the MPOA.
During an interview, on 05/29/25 at 12:38 AM, The Director of Nursing (DON), stated, I cannot find the transfer form, or the bed hold policy in the chart. The DON confirmed they were not sent.
b) Resident 18
On 05/27/25 at 2:03 PM, a record review was completed for Resident #18. The review found the resident had been transferred to an acute care facility for a swollen knee on 04/23/25. The transfer form, bed hold policy and Ombudsman notification was requested from the facility.
On 05/29/25 at 12:38 PM, the Director of Nursing (DON) was interviewed. The DON stated, I cannot find the transfer form, bed hold policy or the ombudsman notification.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and Staff interview the facility failed to ensure foods were probably labelled and discarded when out of date. This failed practice had the potential to affect more than a limite...
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Based on observations and Staff interview the facility failed to ensure foods were probably labelled and discarded when out of date. This failed practice had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 28
Findings include
a) On 05/27/25 at approximately 12:00 PM initial tour of the facility kitchen found the following;
Two (2) salads were in the walk-in cooler with no dates/labels.
One (1) carton of pasteurized eggs in the walk-in cooler with no dated/labels
One (1) carton of heavy whipping cream in the walk-in cooler with no dates/labels
One (1) carton of cream of wheat in the walk-in cooler with no dates/labels
One bag of flour in the dry stock room with no open date
One bag of cheesecake mix in dry stock with no open date
One bag of Tostito corn chips in dry stock room with no open date
An interview with the Dietary Manager (DM) on 05/27/25 at 12:10 PM regarding items not being labeled was completed. The DM stated, We will get this fixed, the staff should know better than this.
confirming the items were not labeled correctly.
Further observations during the initial tour of the kitchen on 05/27/25 revealed one (1) carton of milk with a use by date of 05/22/25.
05/27/25 at approximately 12:30 PM the DM stated, They must have missed that carton of milk when rotating the milk.
On 05/27/25 at approximately 11:30 PM initial tour of the kitchen revealed a cooler that had a seal damaged causing a gap and making the cooler not seal correctly. Further observations of the cooler and milk that was being held inside showed the milk did not feel very cold to touch.
An interview with DM on 05 /27/25 at 11:40 AM who stated, I did not know the seal on the tray line milk cooler was like that.
An observation reveled the DM taking the temperature of the milk. The milk was 41.4 degrees Farenheit. The cranberry juice was 57.6 degrees Farenheit and the temperature inside the cooler was 51 degrees Farenheit.
The DM at this time confirmed the cooler was not properly holding temperatures due to the broken seal on the cooler. When asked what the temperature of the milk and juice should be the DM stated, It (milk and juice) should be under 40 degrees Fahrenheit, but i think they just put that juice back in the cooler(but was not sure the juice were placed back in the cooler). confirming the milk and juice were above holding temperature.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, resident interviews, and documentation review, the facility failed to maintain a proper infection prevention and control in the environment. Facility census 28.
...
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Based on observation, staff interview, resident interviews, and documentation review, the facility failed to maintain a proper infection prevention and control in the environment. Facility census 28.
Findings include:
a) On 05/28/25 at approximately 3:05 p.m., reviewed the facility's water management plan documentation. Upon review of the water management plan discovered that there was no water flow diagram readily available. Interview with employee #48 verified this at the time of discovery. The finding was also acknowledged by the Administrator that the facility does not have a water flow diagram. This finding was also acknowledged by the Administrator upon the exit on 05/29/25.
b) Resident #15
On 05/27/25 at 1:14 PM, a soiled pink bath basin was observed sitting on floor under the sink in Resident #15's room.
On 05/27/25 at 1:17 PM, Registered Nurse (RN) #9 was notified and stated, I thought maybe the sink was leaking but it's not. At this time, RN #9 removed the bath basin from the room.
On 05/28/25 at 9:35 AM, the Director of Nursing (DON) was notified and confirmed the bath basin should not have been sitting under the sink in the floor.
c) Resident #26
On 05/27/25 at 3:40 PM, an observation of oxygen tubing and cannula was found laying on the table and hanging into the floor. RN #9 was notified. RN #9 was asked, does the resident use oxygen? RN #9 confirmed the oxygen tubing and cannula did not belong to the resident.
On 05/28/25 at 9:35 AM, the Director of Nursing (DON) was notified and confirmed the oxygen tubing and cannula should be stored properly; it should not be in the room if the resident does not use oxygen.
d) Resident #11
On 05/27/25 at 1:10 PM, a urinal was observed hanging on the commode handle without being in an appropriate storage container. On 05/27/25 at 1:13 PM, Nurse Aide (NA) #16 removed the urinal from the commode handle. NA #16 stated, let me get this.
On 05/28/25 at 9:35 AM, the Director of Nursing (DON) was notified and confirmed the urinal should be stored properly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to ensure the tray line milk cooler had proper seals to maintain safe temperatures for the milk/juice by holding it under 40 degrees Fahre...
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Based on observation and staff interview, the facility failed to ensure the tray line milk cooler had proper seals to maintain safe temperatures for the milk/juice by holding it under 40 degrees Fahrenheit. This was a random opportunity for discovery and had the potential to affect a limited number of residents residing in the facility. Facility census: 28
Findings include:
On 05/27/25 at approximately 11:30 PM the initial tour of the kitchen revealed a cooler that had a seal damaged causing a gap and making the cooler not seal correctly. Further observations of the cooler and milk that was being held inside showed the milk did not feel very cold to touch.
An interview with Dietary Manager (DM) 05/27/25 at 11:40 AM who stated, I did not know the seal on the tray line milk cooler was like that. The DM took the temperature o placed a thermometer in the cooler and took the temperature of the milk. This temperature reading revealed the milk was 41.4 Fahrenheit and the cranberry juice was 57.6 Fahrenheit. When the DM checked the temperature of the inside of the cooler it was 51.0 degree Fahrenheit. The DM at this time confirmed the cooler was not properly holding temperatures due to the broken seal.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected most or all residents
Based on observation, record review and staff interview, the facility failed to use appropriate alternatives prior to installing bed rails and failed to assess each resident for the risk of entrapment...
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Based on observation, record review and staff interview, the facility failed to use appropriate alternatives prior to installing bed rails and failed to assess each resident for the risk of entrapment from bed rails prior to installation. This failed practice was a random opportunity for discovery and had the potential to affect all residents currently residing in the facility during the Long-Term Care Survey Process. Facility Census: 28.
Findings Include:
a) Facility Bed Rails
An observation on 05/29/25 at 10:00 AM, revealed that all empty beds in the Long-Term Care Unit, and all 28 beds currently occupied by a resident had bed rails installed. The observation revealed that throughout the unit, 4 types of bed rails were being used.
During an interview on 05/29/25 at 10:45 AM, The Maintenance Director (MD), stated, Prior to getting a new admit, we do not inspect the beds or anything. We just work on them if we have a work order for them. We do not have any policy that I know of, about inspecting the bed rails.
During an interview and observation on 05/29/25 at 11:05 AM, of bed rails throughout the facility, the Director of Nursing (DON), stated, Everybody has bed rails the control to the beds is on them. These beds are so old. I have no idea where to find the manufacturer's guideline. As you can see, we have different types of beds and 3 or 4 different types of bed rails.
A record review on 05/29/25 at 11:30 AM, revealed that all residents residing in the facility had a side rail assessment and consent completed and signed by the resident or Medical Power of Attorney (MPOA) upon admission. No side rail assessments had been completed since the admission of the resident. The side rail assessment and consent had no indication that the side rails were assessed for entrapment risk.
During an interview on 05/29/25 at 12:30 PM, The Minimum Data Set Registered Nurse (MDSRN), stated, I do the assessments. I only do the one on admission. I did not know we were required to do anything different. The MDSRN further confirmed that nowhere on the side rail assessment does it mention checking for risk of entrapment.
During an interview on 05/29/25 at 12:45 PM, The DON stated, I will look for the manufacturer's guideline and ask if we have that, but the beds are so old I doubt they are here.
No further information was provided by the end of the survey.
Nov 2023
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to ensure a dignified dining experience for Resident #1. This was a random opportunity for discovery. Resident identifier: #1. Facility ce...
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Based on observation and staff interview, the facility failed to ensure a dignified dining experience for Resident #1. This was a random opportunity for discovery. Resident identifier: #1. Facility census: 26.
Findings included:
a) Resident #1
Observation at 12:53 PM on 10/30/23, revealed Resident #1 had not received her noon meal. The roommate, Resident #13, had already finished eating her lunch.
Nurse Aide (NA) #40 said Resident #1 did not have a tray on the food cart when it arrived, but NA #40 said she had already requested a tray for Resident #1. NA #40 said Resident #1 returned from the hospital yesterday evening. NA #40 said she requested a grilled cheese sandwich from the kitchen when she returned yesterday, So the kitchen should know she is back.
On 10/30/23 at 1:03 PM, a tray arrived for Resident #1. NA #40 confirmed the roommate, Resident #13 received her tray, 20 to 30 minutes earlier than Resident #1.
At 12:49 PM on 11/01/23, the above observations were shared with the Director of Nursing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation and staff interview the facility failed to ensure a call light device was always accessible to Resident #12. This failed practice was a random opportunity for discovery and had th...
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Based on observation and staff interview the facility failed to ensure a call light device was always accessible to Resident #12. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of Residents. Resident identifier: #12. Facility census: 26.
Findings included:
a) Resident #12
On 10/31/23 at 11:15 AM, observation was made of Resident #12 lying in bed without access to a call light device. Licensed Practical Nurse (LPN) #47 located the resident's call light and found it to be tangled up between the bed frame and bed rail with the push button device lying under the resident's bed. LPN #45 verified the call light was not assessable to the Resident. LPN #47 stated to Resident #12, You couldn't have reached that to use if you had to! LPN #45 untangled the call light device and provided it to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment. Ceiling tiles were observed to be stained in three (3) res...
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Based on observation and staff interview, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment. Ceiling tiles were observed to be stained in three (3) resident rooms, a resident lounge area and an office. This failed practice was a random opportunity for discovery and had the potential to only affect a limited number of residents. Resident identifiers: #24, #27, #18. Facility census: 26.
Findings included:
a) Observations on 10/30/23 at 12:06 PM revealed Resident #24's room had five ceiling tiles with watermarks with areas that appeared to have a black substance on the tile.
During an interview with the Director of Nursing (DON) she acknowledged the condition of the ceiling tiles and said, Sometimes it overflows from up there. She further stated she would make maintenance aware. Maintenance Director #6 was present in the hallway and stated he was in the process of changing out ceiling tiles due to the water stains. Ceiling tiles were also observed to be stained in Resident #27 and Resident #18 rooms. The ceiling tiles were also observed stained and missing in the DON's office.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview, the facility failed to ensure appropriate information was communicated to the recei...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview, the facility failed to ensure appropriate information was communicated to the receiving hospital to ensure a safe and effective transition of care. This was true for one of three (3) hospitalizations reviewed during the long-term care survey process. Resident identifier: Resident #279. Facility Census: 26.
Findings included:
a) Resident #279
During record review, on 10/31/23 at 9:54 AM, Resident #279's medical record revealed she was discharged to the local emergency room (ER) on 10/16/23.
Further record review revealed the following notes: (typed as written)
-10/16/23 Resident was discharged from the ECU (Extended Care Unit) to the ER on [DATE] and later transferred to (a local hospital) ICU (Intensive Care Unit). She is expected to readmit to the ECU. She is a long term care patient here.
-10/16/2023 ER called unit to notify resident was being admitted to (a local hospital) ICU for pos occult blood and critical hemoglobin level.
-10/16/2023 at 12:30 PM Resident to ER via carrier for feeling weaker than usual. Skin color pale. Nail beds blue. VS 102/64, 152, 18, 02 Sat 90%.
-10/16/2023 11:30 AM Resident with complaining of feeling very weak, states unable to lift my arms as before. Skin color pale. Nail beds cyanotic.
The record did not reflect a transfer form was completed by nursing staff and sent along with the patient to the receiving facility. There was no evidence the facility had communicated contact information of the physician responsible for the care of the resident, resident representative information including contact information, advance directive information, any special instructions, or precautions for ongoing care.
During an interview, on 10/31/23 at 10:38 AM, the Director of Nursing (DON) acknowledged no transfer information was sent to the receiving facility. The DON said she went to our facility ER, then transferred to (a local hospital) ICU.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure one (1) of two (2) residents reviewed for the care area of pre-admission screening and resident review (PASARR) were referred ...
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Based on record review and staff interview, the facility failed to ensure one (1) of two (2) residents reviewed for the care area of pre-admission screening and resident review (PASARR) were referred for a Level II screening when a serious mental disorder was evident. Resident identifier: #23. Facility census: 26.
Findings included:
a) Resident #23
An initial PASSAR, completed by the referring hospital and signed by a physician on 11/11/21, did not reveal the resident had any mental illness. As a result, the resident did not receive a Level II evaluation.
A review of the medical record found the resident received a diagnosis of bipolar disorder on 01/20/22.
On 10/07/23 a new PASSAR was completed by the facility. The facility did not disclose the resident had a diagnosis of bipolar disorder even though a diagnosis of bipolar disorder was a choice on the MI/MR (mental illness / mental retardation) assessment section of the PASSAR. In addition, the Resident was receiving the antipsychotic medication, Seroquel for treatment which was not disclosed on the PASSAR.
The purpose of a Level II evaluation is to determine if residents with mental disorders or intellectual disabilities are offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.
On 11/01/23 at 4:13 PM, the Director of Nursing (DON) confirmed the 10/07/23 PASSAR completed by the facility failed to disclose the resident has a diagnosis of bipolar disorder which the facility was aware of at the time of competition of the PASSAR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on record review and staff interviews, the facility failed to ensure the resident's Pre admission Screening and Resident Review (PASARR) reflected pre-admission diagnoses for one (1) of two (2) ...
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Based on record review and staff interviews, the facility failed to ensure the resident's Pre admission Screening and Resident Review (PASARR) reflected pre-admission diagnoses for one (1) of two (2) residents reviewed for the category of PASARR. Resident #279 was diagnosed with Bipolar Disorder. Resident identifier #279. Census 26.
Findings Included:
a) Resident #279
Record review, on 11/01/23 at 9:25 AM, of Resident # 279 medical record revealed admitting diagnoses included the following: Bipolar disorder current episode depressed, severe, with psychotic features.
Further review of the medical record revealed a PASARR dated 08/03/23, Section 30 titled Current Diagnosis, was coded None.
Further record review revealed an Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/12/23 Section I titled Active Diagnosis was coded Bipolar.
During an interview, on 11/01/23 at 9:29 AM, the Director of Nursing (DON) acknowledged the PASARR was not coded correctly. The DON stated, I will let the Social Worker know so she complete a new one now.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to implement care plans
for three (3) of 26 Residents whose care...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to implement care plans
for three (3) of 26 Residents whose care plans were reviewed during the long-term care survey process. Resident #17's care plan was not implemented for nutritional needs. Resident #23's care plan was not implemented for a receiving dialysis services. Resident #27's care plan was not implemented for fall prevention. Resident identifiers: #17, #23, and #27. Facility census: 26.
Findings included:
a) Resident #17
Review of the care plan found the current care plan, updated on 09/21/23, stated, Potential for altered nutrition related to no added salt diet with puree consistency. Finger foods
The goal stated, Resident will maintain desired weight within five pounds through next review.
On 11/01/23 at 12:03 PM, the Director of Nursing (DON) was interviewed and asked how the facility would provide finger food to a resident on a pureed diet. The DON said, I don't have an answer for that, you need to ask the dietary manager.
At 12:10 PM on 11/01/23, the Dietary Manager (DM) #4 along with the DON was asked how could the facility provided finger foods to a Resident on a pureed diet. The DM said, There is no way. The DM told the DON, You need to fix that.
b) Resident #23
Review of the care plan found a dialysis care plan, updated on 08/04/23 that reflected the resident required dialysis. The goal stated, Potential for excess fluid, port infection, tiredness from illness/transportation time.
The problem: Resident requires dialysis.
Approaches included Monitor permacath site to right upper chest for signs and symptoms of pain or infection. Obtain vitals, weights and labs as ordered and communicate results to dialysis center as instructed.
On 10/31/23 at 10:56 AM, the DON and RN #26 were asked for evidence of communication between the facility and the dialysis center, such as dialysis pre and post dialysis weights, blood pressure, temperature, pulse, and any communication as to how the resident tolerated dialysis.
The DON said the facility tried sending a notebook with a report for the dialysis center to fill out, but the dialysis center would never send it back. When asked who monitored and recorded the residents pre and post vital signs and pre and post weights on dialysis days, the DON said she guessed that was completed at the center. RN #26 said she had called the dialysis center herself to try to get the paper returned but was told by the dialysis center, providing information to the nursing home was a violation of HIPPA (Health Insurance Portability and Accountability Act) rights. When asked how the facility would know about the resident's care at the dialysis center, the DON said, she figured the dialysis center would call the nursing home if the resident had any problems.
In addition, the DON was unable to provide documentation to verify the facility nursing staff monitor and document the status of the resident's access site(s) upon return from the dialysis treatment.
Review of the medical record supported the interviews from the DON and RN #26. For example, the resident went out of the facility to the dialysis center on 10/30/23. No nurses' notes were written in the medical record on 10/30/23 referencing the resident leaving the facility for dialysis. There was no mention of the resident's condition before and after dialysis. Observation of the access site and condition upon return from dialysis was not recorded anywhere in the medical record. The only vital sign recorded on 10/30/23 was a blood pressure (108/60) obtained at 9:28 PM.
On 11/01/23 at 8:35 AM, the resident's physician said obtaining information from the dialysis had been a problem. She said the dialysis center has had some issues with their services. She said she would tell the medical director and maybe he could call the center.
On 11/01/23 at 9:46 AM, the DON confirmed the care plan was not implemented.
c) Resident #27
During a medical record review on 10/31/23 at 9:06 AM, the event report for Resident # 27 revealed the resident fell on [DATE]. The report revealed the resident said he was trying to get up to get his television remote and slid because of the socks he had on. The report went on to state the resident was found sitting on the floor beside his bed behind his wheelchair. The report revealed the resident had personal socks on that were not nonskid.
Resident #27 care plan review dated 10/2/2023, noted that resident was care planned as a fall risk. The care plan indicated to keep water, TV remote and other items of frequent use within his reach when in the room.
During interview, with Resident #27, the resident stated his remote control was over on his heater and he was trying to get up to get it. Resident #27 was noted to have capacity in the medical record.
The event report that noted the fall also revealed this fall was not reviewed on the care plan. During an interview, with the Director of Nurses (DON), on 11/01/23 at 1:50 PM, the DON stated that he may have gotten up and placed the remote away from his bed and when they put him back down they may not have seen it to put it closer to him. The DON did agree that it should have been closer to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on staff interview and record review, the facility failed to revise the care plan after Resident #1's dentures were lost. This was true for one (1) of fifteen residents whose care plans were rev...
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Based on staff interview and record review, the facility failed to revise the care plan after Resident #1's dentures were lost. This was true for one (1) of fifteen residents whose care plans were reviewed during the long-term care survey. Resident identifier: #1. Facility census: 26.
Findings included:
a) Resident #1
On 10/30/23, at 12:05 PM, Resident #1 said she had no lower dentures. Resident #1 said, They threw them away, about 2 months ago. She said she put her teeth in a Styrofoam cup on her over - the - bed table and someone threw the cup away. She said, They don't pay attention.
Review of the current care plan dated 10/30/23 reflected the Resident had poor oral status related to use of upper and lower dentures.
The goal associated with the problem revealed the resident would have no signs or symptoms of infection or decreased nutritional status.
Interventions included:
Encourage the resident to perform oral care at least twice daily with toothbrush, toothpaste and mouthwash.
On 11/01/23 at 10:55 AM the Director of Nursing (DON) was asked if the Resident had an appointment to see a dentist. The DON said, she doesn't need one, she has dentures.
At 12:51 PM on 11/01/23, The surveyor and the DON visited the resident in her room. Resident #1 related the same story to the DON about her missing bottom denture. The DON searched the room and was unable to locate the lower dentures. The resident said she didn't want to be bothered with getting a new lower denture. The resident said,I don't want to go through all that, too much for me. The resident was asked if she was able to get out of bed and clean her own dentures, she said, No, I can't walk by myself.
After leaving the room, the DON said she did not know the denture was missing and no one said anything. When asked why staff would not know about the lower denture when they would be responsible for assisting with cleaning the dentures, the DON said she guessed someone should have known.
On the afternoon of 11/01/23, the care plan was reviewed with the DON. No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review and staff interview, the facility failed to ensure a resident receiving oxygen had a physician's order for usage. This was found for one (1) of one (1) Resident rev...
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Based on observation, record review and staff interview, the facility failed to ensure a resident receiving oxygen had a physician's order for usage. This was found for one (1) of one (1) Resident reviewed for respiratory care. Resident identifier: #20. Facility census: 26.
Findings included:
a) Resident #20
Observation at 12:18 PM on 10/30/23 revealed the resident was receiving oxygen at a flow rate of 2.5 liters via nasal cannula.
Review of the current care plan found the resident was receiving oxygen related to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD.)
Further review of the current physician's orders found there was no order for the resident to receive any oxygen.
On 10/31/23 at 9:48 AM, Registered Nurse (RN) #26 was interviewed and asked if Resident #20 had an order for oxygen and if so, what flow rate of oxygen should the resident be receiving. RN #20 looked at the medical records of Resident #20 and said, I don't see an order, but I'll get one for 2 liters of oxygen. That's our protocol. The Director of Nursing (DON) was present and said, We should look at what the respiratory therapist recommended and call the doctor. The DON looked at the respiratory therapist's notes and said 3 liters of oxygen was the recommended flow rate.
On 10/31/23 at 9:55 AM, the DON and the surveyor observed the resident in his room receiving oxygen at a flow rate of 2.5 liters.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview the facility failed to administer an extended-release medication within the appropriate guidelines for Resident #1. This failed practice was a ...
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Based on observation, record review, and staff interview the facility failed to administer an extended-release medication within the appropriate guidelines for Resident #1. This failed practice was a random opportunity for discovery and had the potential to affect only a limited number of Residents. Resident identifier: #1. Facility census: 26.
Findings included:
During observation of medication pass for Resident #1, Licensed Practical Nurse (LPN) #43 crushed a Metoprolol Extended Release (ER) 25mg tablet. LPN #43 placed the crushed tablet in applesauce for administration to Resident #1. The applesauce mixture also contained a crushed Norvasc 10 mg tablet, two (2) Vitamin D 3 capsules (whole not crushed) and a Neurontin 300 mg capsule (whole not opened).
During an interview on 10/31/23 at 09:50 AM the Facility Pharmacist stated, The Metoprolol Extended-Release tablet can be scored and cut in half, but it is not a crushable medication.
On 10/31/23 at 01:35 PM the Director of Nursing (DON) provided the Common Oral Dosage Forms That Should Not Be Crushed Do Not Crush list utilized by the facility. The DON stated, [LPN #43's name] told me a bit ago she crushed a medication that should not have been crushed. The DON verified the Metoprolol XR medication should have not been crushed, If its on the list, it should not have been crushed.
Record review of Common Oral Dosage Forms That Should Not Be Crushed showed Metoprolol Succinate XL tablet to be on the list indicated the medication should be administered whole.
Record review showed an order for Metoprolol Succinate tablet extended release 1 tablet oral every 12 hours.
During an interview on 11/01/23 at 09:49 AM, LPN #43 stated, I realized I shouldn't have crushed the extended-release tablet after she (the DON) brought me the 'do not crush list'.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on observation, policy review, resident council meeting and staff interview the facility failed to make grievances forms accessible to all residents and/or residents family/representatives resid...
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Based on observation, policy review, resident council meeting and staff interview the facility failed to make grievances forms accessible to all residents and/or residents family/representatives residing in the facility. This had the potential to affect more than a limited number of residents living in the facility. Facility census: 26.
Findings included:
a) Grievance Forms
A review of the facility policy titled Grievance/Concern with a revision date 03/21/18 and a reviewed date of 03/20
.PROCEDURE:
A. Person making the complaint will notify the Charge Nurse on duty and ask for a complaint form. If present the charge Nurse will offer to all the Grievance Officer to speak with the patient/family/visitor.
The federal guidelines indicate the following:
483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents ' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously;
a) Grievance Forms
During the Long-Term Care Survey Process from 10/31/23 to 11/01/23 many observations throughout the facility revealed no evidence of grievance forms being accessible to the residents and/or resident representatives.
During the Resident Council Meeting held on 10/31/23 at 1:18 PM, the residents as a group were asked the question, Do you know how to file a grievance? Do you know where to access your grievance forms? The residents as a group stated No, we don't. We just tell (Social Worker's name).
During an interview, on 10/31/23 at 3:12 PM, the Social Worker (SW) stated the grievance forms are in a folder behind the nurse's desk. Anyone can ask us to fill it out.
During an interview on 10/31/23 at 3:13 PM, Registered Nurse (RN) #26 stated the residents come to the desk, we get the form, and we fill it out for them. Then we fold it and put it under either the Director of Nursing's door or the SW's door.
During an interview, on 10/31/23 at 3:14 PM, the SW acknowledged the grievance forms were not accessible to all residents or representatives.
During an interview, on 10/31/23 at 3:14 PM, RN #26 acknowledged the grievance forms were not accessible to all residents or representatives. Then stated, We will have a folder put in the library for the residents and family to access the grievance forms.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
Based on record review, Resident Council meeting and staff interviews, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the...
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Based on record review, Resident Council meeting and staff interviews, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 26
Findings Included:
a) Activity Program
During the Resident Council Meeting held on 10/31/22 1:16 PM, the residents group was asked the question, Are you satisfied with your involvement in group activities? The following concerns were voiced?
The residents replied:
-We only have group activities every other weekend.
-We get packets to do on the weekends, they call that group activities.
-Nothing to do in the evenings, we eat dinner and go to bed.
-Sometimes they turn the TV on in the Dining Room for a ball game but no other weekend activities.
During a review of three months of the monthly activity calendars revealed the following activities on weekends and evenings;
October 2023:
- Sunday, 10/01/23 11:30 AM Church on TV and Activity Packets
- Saturday, 10/14/23 Activity Packets 2:00 Movie
- Sunday, 10/15/23 11:30 AM Church on TV and Activity Packets
- Friday, 10/20/23 6:30 PM Riverside Church of God
-Saturday, 10/28/23 Activity Packets 2:00 Movie
September 2023:
Saturday, 09/02/23 Activity Packets 2:00 Movie
Sunday, 09/03/23 11:30 AM Church on TV and Activity Packets
Friday, 09/15/23 6:30 PM Riverside Church of God
Saturday, 09/16/23 Activity Packets 2:00 Movie
Friday, 09/17/23 11:30 AM Church on TV and Activity Packets
Saturday, 09/23/23 Activity Packets 2:00 Movie
Saturday, 09/30/23 Activity Packets 2:00 Movie
August 2023:
-Saturday, 08/12/23 Activity Packets 2:00 Movie
-Sunday, 09/13/23 Activity Packets 11:30 Church on TV
-Friday, 08/18/23 6:30 PM Riverside Church of God
-Saturday,08/26/23 Activity Packets 2:00 Movie
The Monthly Activity Calendars revealed only one (1) evening activity a month. It also revealed that every other weekend group activities were provided.
During an interview on 11/01/23 at 3:16 PM, the Activity Director (AD) said she had two (2) assistants, but one had been used as a Nurse Aide (NA) because they were short staffed.
The other assistant helps with laundry. We only have group activities every other weekend, the weekends with no groups gets an individualized activity packet. The weekend nurse gives out the packets for us when we are not here. The AD stated we have one evening activity a month, we can not get our volunteers to come back after COVID.
The AD was asked, Why are your activity assistants not providing the evening activities? The AD stated, I share the one assistant with Laundry and I should be getting my other assistant back next month.
The AD was informed of the information provided in the Resident Council meeting held on 10/31/23.
During an interview on 11/01/23 at 3:42 PM, the Director of Nursing (DON) stated, one of the Activity Assistants did assist with laundry. The DON said, The other I have been utilizing because I have been short staffed and I pull her back to be a NA. I pulled her because a clean butt and being feed is more important than activities.
The DON was asked, Are activities for mental, physical and psychosocial needs not important?
The DON stated, Their care comes first, and when you short staffed I will pull wherever I can and wherever I want.
During an interview on 11/01/23 at 4:05 PM, the DON stated the NA has been working since 02/03/23 as a Nurse Aide. I have been short staffed.
This surveyor stated, You usually have four (4) to five (5) NA's on 7-3 shift, seven (7) to eight (8) NA's on evening and your census average is about 27 Residents, is that not enough staff for 27 residents?
This surveyor informed the DON that Activities would be cited for lack of activities due to her utilizing the activity staff to do other jobs instead of providing the residents with the Activities of interest for evenings and weekends. The DON stated the NA would be back to activities in a few weeks after the four (4) new ones get trained.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, the facility failed to have documentation to support ongoing communication, coordination and collaboration between the nursing home and the dialysis center ...
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Based on record review and staff interview, the facility failed to have documentation to support ongoing communication, coordination and collaboration between the nursing home and the dialysis center for one (1) of one (1) Resident reviewed for the care area of dialysis. In addition, there was no evidence to support an ongoing assessment of the resident's condition and monitoring for possible complications before and after dialysis treatments received at a certified dialysis facility. Resident identifier: 23. Facility census: 26.
Findings included:
a) Resident #23
During the initial resident screening process of the survey on 10/30/23, observation of the Resident's room at 11:30 AM on 10/30/23 found the resident was not present. When asked where the resident might be, Registered Nurse (RN) #26 said the resident was at the dialysis center and should return to the facility around 4:00 PM.
Review of the current medical record on the morning of 10/31/23, found no physician's orders for dialysis services.
On 10/31/23 at 10:49 AM, the Director of Nursing (DON) reviewed the medical record and said there are no physician's orders for dialysis treatment. The DON confirmed the Resident does receive dialysis services and at an outpatient dialysis center three (3) times a week on Mondays, Wednesdays, and Fridays.
On 10/31/23 at 10:56 AM, the DON and RN #26 were asked for evidence of communication between the facility and the dialysis center, such as dialysis pre and post dialysis weights, blood pressure, temperature, pulse, and any communication as to how the Resident tolerated dialysis.
The DON said the facility tried sending a notebook with a report for the dialysis center to fill out but the dialysis center would never send it back. When asked who monitors and records the residents pre and post vital signs and pre and post weights on dialysis days, the DON said she guessed that was completed at the center. RN #26 said she had called the dialysis center herself to try to get the paper returned but was told by the dialysis center, providing information to the nursing home was a violation of HIPPA (Health Insurance Portability and Accountability Act) rights. When asked how the facility would know about the Resident's care at the dialysis center, the DON said, she figured the dialysis center would call the nursing home if the Resident had any problems.
In addition, the DON was unable to provide documentation to verify the facility nursing staff monitor and documentation of the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications.
Review of the medical record supported the interviews from the DON and RN #26. For example, the Resident went out of the facility to the dialysis center on 10/30/23. No nurses notes were written in the medical record on 10/30/23 referencing the resident left the facility for dialysis. There was no mention of the Resident's condition before and after dialysis. Observation of the access site and condition upon return from dialysis was not recorded anywhere in the medical record. The only vital sign recorded on 10/30/23 was a blood pressure (108/60) obtained at 9:28 PM.
On 11/01/23 at 8:35 AM, the Resident's physician said obtaining information from the dialysis had been a problem. She said the dialysis center has had some issues with their services. She said she would tell the medical director and maybe he could call the center.
Review of the care plan found a dialysis care plan, updated on 08/04/23:
The problem: Resident requires dialysis.
The goal: Potential for excess fluid, port infection, tiredness from illness/transportation time.
Approaches included:
Monitor permacath site to right upper chest for signs and symptoms of pain or infection.
Obtain vitals, weights and labs as ordered and communicate results to dialysis center as instructed.
On 11/01/23 at 9:46 AM, the DON confirmed the care plan was not implemented.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on record review and staff interview the facility failed to ensure nurse staffing information was posted on a daily basis. This was a random opportunity for discovery and has the potential to af...
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Based on record review and staff interview the facility failed to ensure nurse staffing information was posted on a daily basis. This was a random opportunity for discovery and has the potential to affect all residents at the facility. Facility census: 26.
Findings included:
a) Staff posting
At 10:40 AM on 10/30/23, observation revealed the nurse staffing information posted for public view at the nurses station was dated 10/27/23.
The Director of Nursing (DON) confirmed the posting was not current for todays date - 10/30/23.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to maintain proper infection control standards during wound care. This failed practice was a random opportunity for discovery and had the p...
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Based on observation and staff interview the facility failed to maintain proper infection control standards during wound care. This failed practice was a random opportunity for discovery and had the potential to affect only a limited number of fesidents. Resident identifier: #79. Facility census: 26.
Findings included:
a) Resident #79
Record review showed an order for Santyl ointment; 250 unit/gram for amount of a thin layer, topical. Special Instructions: Cleanse area to 5th right toe area with Normal Saline. Pat dry. Apply thin layer of Santyl, apply dry 4x4 gauze, wrap with Curlex daily.
During observation of wound care on 10/31/23 at 11:22 AM, Licensed Practical Nurse (LPN) #43 did not disinfect the residents over bed table (OBT) or place a barrier down prior to initiating wound care. The Residents drink cup, half eaten cookie, and dirty napkin were left on the OBT. Dressing supplies were laid directly in a sticky substance on the table. LPN #43 laid the opened Santyl ointment tube directly down on the table. Ointment was protruding out of the tube opening and touched the table. LPN #43 proceeded to pick up the tube of ointment and scrap the ointment off the tube with a Q-tip. LPN #43 then applied the ointment the Resident's 5th toe wound.
During an interview on 11/01/23 at 12:00 PM the Director of Nursing stated, You mean they didn't even use a Clorox wipe or anything? The DON verified the over the bed table should have been disinfected and a barrier placed prior to initiating the wound care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to administer and complete pneumococcal vaccines series for three...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to administer and complete pneumococcal vaccines series for three (3) of five (5) residents reviewed for immunizations. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #23, #2 and #24. Facility census: 26.
Findings included:
a) Resident # 23
Resident #23's current admission date was 11/11/21, and the most recent return was on 06/28/23.
Review of the Residents immunizations showed Resident #23 was administered the Pneumococcal polysaccharide vaccine (PPSV23) on 12/30/21. No other pneumococcal vaccines were given.
Record review showed the Resident to have an immunocompromising condition of end stage renal failure and be [AGE] years of age. Per the Centers for Disease Control and Prevention's (CDC) pneumococcal guidelines, the Resident's age, diagnoses and previous vaccination history qualified the resident to receive a second pneumococcal vaccine (Prevnar 20, or Prevnar 15) one year past 12/30/21.
On 11/01/23 at 03:36 PM, Registered Nurse (RN) #45 stated, Yes, [Resident #23's name] should have had another pneumonia shot by now, especially with her going to dialysis and all her other problems.
b) Resident # 2
Resident #2's current admission date was 04/03/23.
Review of the Residents immunizations showed Resident #2 was administered the pneumococcal conjugate vaccine (PCV13) on 08/28/19. No other pneumococcal vaccines were given.
Record reviewed showed the Resident to be [AGE] years of age. Per the Centers for Disease Control and Prevention's (CDC) pneumococcal guidelines, the Resident's age, diagnosis, and previous vaccination history qualified the Resident to receive a second pneumococcal vaccine (Prevnar 20, or Prevnar 23) one year past 09/28/19.
On 11/01/23 at 03:37 PM, Registered Nurse (RN) #45 confirmed Resident #2 should have been administered a second pneumococcal vaccine.
c) Resident # 24
Resident #24's current admission date was 12/09/21.
Review of the Residents immunizations showed Resident #23 was administered the Pneumococcal polysaccharide vaccine (PPSV23) on 01/13/22. No other pneumococcal vaccines were given.
Record reviewed showed the Resident to be [AGE] years of age. Per the Centers for Disease Control and Prevention's (CDC) pneumococcal guidelines, the Resident's age and previous vaccination history qualified the Resident to receive a second pneumococcal vaccine (Prevnar 20, or Prevnar 15) one year past 01/13/22.
On 11/01/23 at 03:38 PM, Registered Nurse (RN) #45 confirmed Resident #24 was not given the completed pneumococcal vaccine series.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected most or all residents
Based on observation and staff interview, the facility failed to ensure licensed nurse staffing information based on payroll information was accurately reported to the Centers for Medicare and Medicai...
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Based on observation and staff interview, the facility failed to ensure licensed nurse staffing information based on payroll information was accurately reported to the Centers for Medicare and Medicaid Services (CMS.) This has the potential to affect all residents at the facility. Facility census: 26.
Findings included:
a) Payroll Based Journal (PBJ)
Review of the facility's Payroll Based Journal (PBJ) data from the Certification And Survey Provider Enhanced Reports (CASPER) found the facility did not have licensed nursing coverage 24 hours a day for 51 days during the third quarter of 2023:
04/01/23, 04/02/23, 04/05/23, 04/08/23, 04/09/23, 04/10/23, 04/12/23, 04/13/23, 04/14/23,
04/15/23, 04/16/23, 04/19/23, 04/20/23, 04/21/23, 04/22/23, 04/23/23, 04/26/23, 04/29/23, and 04/30/23.
05/01/23, 05/06/23, 05/07/23, 05/10/23, 05/11/23, 05/13/23, 05/14/23, 05/17/23, 05/18/23,
05/19/23, 05/20/23, 05/21/23, 05/24/23, 05/27/23, 05/28/23, 05/29/23, and 05/31/23.
06/03/23, 06/04/23, 06/07/23, 06/10/23, 06/11/23, 06/12/23, 06/14/23, 06/15/23, 06/16/23, 06/17/23, 06/18/23, 06/21/23, 06/24/23, 06/25/23, and 06/28/23.
On 10/31/23 at 2:32 PM, the Director of Nursing (DON) reviewed the report and said, someone submitted the wrong information. The DON and the surveyor reviewed the payroll information of licensed nursing staff working and determined the facility did have nursing staff 24 hours a day as required.
On 11/01/23 at 10:18 AM, the Administrator confirmed she had investigated the situation and had determined the facility made an error when entering and transmitting the licensed nurse staffing hours.
Apr 2022
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to notify a resident representative of a change in condition. This was discovered for one (1) of four (4) residents reviewed fo...
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Based on medical record review and staff interview the facility failed to notify a resident representative of a change in condition. This was discovered for one (1) of four (4) residents reviewed for the care area of accidents during the Long-Term Care Survey Process. Resident # 25 had a fall on 03/18/22 and the resident representative was not contacted. Resident identifier: #25 Facility census: 33
Findings included:
a) Resident #25
During a medical record review on 04/20/22 for Resident #25, it was discovered the resident had a fall on 03/23/22. The Fall Risk Assessment revealed the physician had been contacted, but there was no evidence to show the resident representative had been contacted.
An interview with the Director of Nursing (DON) on 04/20/22 at 9:08 AM, verified she was unable to find any progress notes indicating the family had been contacted regarding the fall Resident #25 had on 03/23/22.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment for Resident #25 in the area of restraints and alarms. This was foun...
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Based on medical record review and staff interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment for Resident #25 in the area of restraints and alarms. This was found for one (1) of fourteen MDS assessments reviewed during the Long-Term Care Survey Process. Resident identifier: #25 Facility census: 33.
Findings included:
a) Resident #25
During a medical record review on 04/18/22 for Resident #25, it was discovered the quarterly MDS assessment completed on 03/18/22 had not been coded to reflect chair and bed tab alarms were being used daily by the resident.
An interview with the Director of Nursing (DON) on 04/20/22 at 9:08 AM, verified the MDS had not been coded correctly for the daily use of a chair and bed tab alarm for Resident #25.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to develop an accurate comprehensive person-centered care plan for a resident receiving respiratory services. This was discover...
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Based on medical record review and staff interview the facility failed to develop an accurate comprehensive person-centered care plan for a resident receiving respiratory services. This was discovered for one (1) of fourteen care plans reviewed during the Long-Term Care Survey Process. The intervention for respiratory care for Resident #9 did not have the correct liters per minute of oxygen to be administered via a nasal canula. Resident identifier: # 9 Facility census: 33
Findings included:
a) Resident #9
During a medical record review on 04/19/22, it was discovered the care plan interventions for oxygen therapy did not include the correct two (2) liters of per minute of oxygen to be received via a nasal canula for Resident #9.
In an interview with the Director of Nursing (DON) on 04/19/22 at 11:36 AM, verified the interventions for oxygen therapy had three (3) liters of oxygen instead of the correct two (2) liters of oxygen to be received by Resident #9.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to revise a care plan in the area of fall risk. This was discovered for one (1) of fourteen care plans reviewed during the Long...
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Based on medical record review and staff interview the facility failed to revise a care plan in the area of fall risk. This was discovered for one (1) of fourteen care plans reviewed during the Long-Term Care Survey Process. The care plan for Resident #9 had not been revised to indicate chair and bed alarms were being used daily. Resident identifier: #9 Facility census: 33
Findings included:
a) Resident #9
During the medical record review on 04/19/22 for Resident #9, the care plan indicated resident was to be evaluated for chair and bed tab alarms. The care plan had not been revised on 04/14/22 to reveal the resident had been using a chair and bed tab alarm daily since 01/26/22.
An interview with the Director of Nursing (DON) on 04/19/22 at 11:36 AM, verified the interventions to evaluate the need for a bed and chair alarm had not been revised to indicate Resident #9 was using the chair and bed tab alarms daily.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview, the facility failed to ensure the resident's environment was as free from accident hazards as possible. The medication cart was observed to be unl...
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Based on medical record review and staff interview, the facility failed to ensure the resident's environment was as free from accident hazards as possible. The medication cart was observed to be unlocked and unattended in the hallway. This was a random opportunity for discovery that had the potential to affect a limited number of residents. Facility census: 33.
Findings included:
a) Medication Cart
On 04/20/22 at 10:04 AM, the medication cart was noted to be placed in the hallway, in front of a storage room. A resident room was located next to the storage room. No staff member was in attendance.
On 04/20/22 at 10:05 AM, the Director of Nursing (DON) was notified the medication cart was unlocked with no staff in attendance. The DON locked the medication cart.
On 04/20/22 at 10:06 AM, Registered Nurse (RN) #19 returned to the medication cart. RN #19 stated the medication cart key was jamming and she was afraid the cart wouldn't unlock if she had locked it.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure oxygen therapy was administered in accordance with professional standards of practice. Resident #134's oxygen tubing and humid...
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Based on observation and staff interview, the facility failed to ensure oxygen therapy was administered in accordance with professional standards of practice. Resident #134's oxygen tubing and humidification bottle were not dated when changed. This was a random opportunity for discovery. Resident identifier: #134. Facility census: 33.
Findings included:
a) Resident #134
On 04/18/22 at 12:01 PM, Resident #134 was noted to be wearing supplemental oxygen via nasal cannula. The oxygen tubing and humidification bottle were not dated to indicate when they had been last changed.
On 04/18/22 at 12:03 PM, the Director of Nursing confirmed Resident #134's oxygen tubing and humidification bottle were not dated to indicate when they were changed. Resident #134 stated it hadn't been very long since they were changed.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview, the facility failed to ensure residents were assessed for pneumococcal vaccination status and offered vaccination if appropriate. This was true fo...
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Based on medical record review and staff interview, the facility failed to ensure residents were assessed for pneumococcal vaccination status and offered vaccination if appropriate. This was true for one (1) of five (5) residents reviewed for influenza and pneumonia vaccinations. Resident identifier #25. Facility census: 33.
Findings included:
a) Resident #25
Record review of the facility's policy titled LTC Influenza and Pneumococcal Vaccination with effective date April 2003 and revision date March 2018 showed the following procedures to be performed:
- Nursing staff were to assess the pneumococcal vaccination status of all residents and identify unvaccinated residents who are at risk for pneumococcal disease.
- If the resident was a candidate for the vaccination, the physician would be notified, and consent obtained from resident and/or responsible person to proceed with vaccination.
Review of Resident #25's medical records showed no documentation that the resident was assessed for pneumococcal vaccination status and had received a pneumococcal vaccination if appropriate.
During an interview on 04/20/22 at 9:33 AM, the Director of Nursing confirmed Resident #25 had not been assessed for nor had received pneumococcal vaccination.
No further information was provided through the completion of the survey.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview the facility failed to properly store food in a safe and sanitary manner in accordance with the professional standards for food service safety. The foods sto...
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Based on observation and staff interview the facility failed to properly store food in a safe and sanitary manner in accordance with the professional standards for food service safety. The foods stored in the kitchen and nourishment room were not labeled correctly and foods were not discarded when expired. The failed practice had the potential to affect more than a limited number of residents currently receiving nutrition from the facility's kitchen. Facility Census: 33
Findings Included:
a) Kitchen
An initial tour of the kitchen with the Certified Dietary Manager (CDM) beginning on 04/18/22 at 11:20 AM found the following failed practices:
-- Reach in Refrigerator
--a pan of Lemon Jello use by date 04/08/22
--a bowl of Cream of Wheat use by date 04/14/22
--a bowl of Applesauce with no date
The CDM indicated these things needed to be discarded because they were not dated when opened and/or past the use by date listed.
-- Deep freeze
--2 opened bags of chicken wings no open date
--2 opened bags of onion rings no open date
--2 opened bags of hushpuppies no open date
--2 opened bags of popcorn chicken no open date
--4 opened bags of french fries no open date
--2 opened bags of fish nuggets no open date
--3 opened bags of chicken patties no open date
--1 opened bag of cheese sticks no open date
--2 opened bags of sweet potato fries no open date
The CDM indicated these things needed to be discarded because they were not dated when opened.
During an interview on 04/18/22 at 11:23 AM CDM stated I just had an in-service on labeling foods after opening.
During an interview on 04/18/22 at 11:25 AM Dietary Aide #32 stated nothing in the freezer has dates and it has all been opened. I will try to do better and make sure the aides do better on labeling.
-- Dessert freezer
--opened bag of cubed potatoes no open date
--opened bag of french fries no open date
The CDM indicated these things needed to be discarded because they were not dated when opened.
-- Storage Bins
--Liquid Thickener bin had no label of contents or date.
--A bin with bread crumbs and rice had no label of contents or date.
The CDM indicated these things needed to be discarded because they were not dated when opened.
-- Walk in Refrigerator
--opened roll of bologna no open date
--opened box of sliced ham no open date
--opened bag of carrots no open date
The CDM indicated these things needed to be discarded because they were not dated when opened.
-- Walk in Freezer
--three (3) gallon opened container of vanilla ice cream no open date
--opened box of pizza dough no open date
--opened box of dinner rolls no open date
--opened block of sliced cheese no open date
--opened box of cubed steak no open date
--opened box of ground beef patties no open date
--opened box of cookie dough no open date
-- opened box of lima beans no open date
The CDM indicated these things needed to be discarded because they were not dated when opened.
-- Walk in Milk Cooler
--opened carton of liquid eggs no open date
--opened package of boiled eggs no open date
--opened box of sliced bacon no open date
--opened box of turkey sausage patties no open date
--opened carton of oats no open date
--opened bag of brown sugar no open date
The CDM indicated these things needed to be discarded because they were not dated when opened.
An In-service of label and dating on 03/31/22
.Food items must have a date when received, when opened and when it expires. If you open a food item, you must put a open date and when it expires
b) Nourishement Room
An initial tour of the nourishment room with the Director of Nursing (DON) beginning on 04/19/22 at 9:32 AM found the following failed practices:
-- Refrigerator
--tray of homemade sandwiches not labeled of contains or
--opened package of cheddar cheese no open date
--opened packaged of swiss cheese no open date
--two (2) opened bottles of fruit punch no open date
--opened container of butter no open date
--opened bottle of brown mustard manufactured expiration date 02/22/22
--opened jar of mayonnaise no open date
--opened bottle coffee creamer no open date
--opened bottle of chocolate syrup no open date
--opened bottle of strawberry syrup no open date
The DON indicated these things needed to be discarded because they were not dated when opened or expired.
-- Freezer
--opened box of ice cream cake no open date
--opened pint of chocolate ice cream no open date
-- two (2) opened boxes of muffins no open date
The DON indicated these things needed to be discarded because they were not dated when opened.
-- pantry cabinet
--can of cream of chicken soup manufactured expiration date 02/18/22
The DON indicated the can of soup needed to be discarded because they were expired.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected multiple residents
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Based on medical record review and staff interview, the facility failed to inform all residents, their representatives, and families by 5:00 PM the next calendar day following the occurrence of a si...
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Based on medical record review and staff interview, the facility failed to inform all residents, their representatives, and families by 5:00 PM the next calendar day following the occurrence of a single confirmed COVID-19 infection. This was true for three (3) of three (3) residents reviewed for COVID-19 notification. Resident identifiers: #15, #19, #27. Facility census: 33.
Findings included:
a) Resident #15
Review of the facility's Staff Line Listing for COVID-19 Outbreak showed the facility had two (2) staff members who tested positive for COVID-19 on 01/16/22.
Review of Resident #15's medical records showed the following note written on 01/18/22 at 12:24 PM, [Resident representative's name] notified that ECU [extended care unit] is in a covid outbreak status and that all residents and staff are being tested.
b) Resident #19
Review of the facility's Staff Line Listing for COVID-19 Outbreak showed the facility had two (2) staff members who tested positive for COVID-19 on 01/16/22.
Review of Resident #19's medical records showed the following note written on 01/18/22 at 12:03 PM, Voicemail left for [resident representative's name] notifying her that ECU [extended care unit] is in a covid outbreak status and all residents and staff are being tested.
c) Resident #27
Review of the facility's Staff Line Listing for COVID-19 Outbreak showed the facility had two (2) staff members who tested positive for COVID-19 on 01/16/22.
Review of Resident #27's medical records showed the following note written on 01/18/22 at 12:07 PM, Spoke with [resident representative's name] that ECU [extended care unit] is in covid outbreak status and that all residents and staff are being tested.
d) Interview
During an interview on 04/20/22 at 11:16 AM, the Director of Nursing confirmed Resident #15, #19, and #27's resident representatives were not notified by 5:00 PM the next day following the occurrence of a single confirmed COVID-19 infection.
No further information was provided through the completion of the survey.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most West Virginia facilities.
Concerns
- • 39 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Montgomery General Hospital's CMS Rating?
CMS assigns MONTGOMERY GENERAL HOSPITAL an overall rating of 2 out of 5 stars, which is considered below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Montgomery General Hospital Staffed?
CMS rates MONTGOMERY GENERAL HOSPITAL's staffing level at 3 out of 5 stars, which is average compared to other nursing homes.
What Have Inspectors Found at Montgomery General Hospital?
State health inspectors documented 39 deficiencies at MONTGOMERY GENERAL HOSPITAL during 2022 to 2025. These included: 39 with potential for harm.
Who Owns and Operates Montgomery General Hospital?
MONTGOMERY GENERAL HOSPITAL is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 44 certified beds and approximately 33 residents (about 75% occupancy), it is a smaller facility located in MONTGOMERY, West Virginia.
How Does Montgomery General Hospital Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, MONTGOMERY GENERAL HOSPITAL's overall rating (2 stars) is below the state average of 2.7 and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Montgomery General Hospital?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Montgomery General Hospital Safe?
Based on CMS inspection data, MONTGOMERY GENERAL HOSPITAL has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Montgomery General Hospital Stick Around?
MONTGOMERY GENERAL HOSPITAL has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Montgomery General Hospital Ever Fined?
MONTGOMERY GENERAL HOSPITAL has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Montgomery General Hospital on Any Federal Watch List?
MONTGOMERY GENERAL HOSPITAL is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.