Montgomery Nursing and Rehabilitation Center: Choking Citation


A nursing home in Montgomery, New York has received 20 health and safety code citations in the last four years.

Montgomery Nursing and Rehabilitation Center received 20 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on July 24, 2021. The Montgomery nursing home’s citations resulted from a total of five inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not undertake adequate measures to prevent residents from sustaining accidents such as choking. Section 483.25 of the Federal Code requires nursing homes to ensure residents receive adequate supervision to prevent accidents. A May 2021 citation found that Montgomery Nursing and Rehabilitation Center failed to ensure such. The citation states specifically that the facility did not ensure a resident received their prescribed diet or monitoring while eating, and as such the resident choked while eating breakfast, requiring intervention from emergency medical services. The citation goes on to state that the resident’s physician had placed an order for a chopped solids, thin liquid diet, but on the day of the choking incident the resident was given a regular meal. During the incident, according to a nurse at the facility, “no staff were assigned to monitor the resident.” The facility’s administrator states in an interview that “there was a multi system failure” contributing the resident’s choking incident, and that there “was no system for a second check in place to ensure that residents are given meals in adherence with physician’s orders.”

2. The nursing home failed to maintain adequate infection control procedures. Section 483.80 of the Federal Code stipulates that nursing homes must undertake to prevent the development and spread of disease by creating and maintaining an infection prevention and control plan. A November 2019 citation found that Montgomery Nursing and Rehabilitation Center failed to ensure such. The citation states specifically that a survey could not ensure “the facility maintained proper hand hygiene to prevent cross contamination and the spread of infection” in connection to one resident who received an “unsterile pressure ulcer dressing change.” The citation goes on to describe an incident in which, during the resident’s dressing change, their wound site “was observed without a dressing on” and a nurse cleaned the wound “without changing gloves, washing hands or using sanitizer.” A plan of correction undertaken by the facility included re-education of nurses with competency issues.


The New York nursing home’s citations include two for deficient infection control policies.

3. Records show that Montgomery Nursing and Rehabilitation Center also received a citation for deficient infection prevention and control procedures in July 2019. The citation states that a resident’s foley catheter bag and tubing were observed resting on the floor, with the tubing dragging on the floor as the resident was wheeled to physical therapy. In an interview, the facility’s physical therapist “confirmed that the foley catheter and tubing were on the floor” and that “the foley catheter and tubing should not be touching the ground.” A plan of correction undertaken by the facility included the counseling of the staff in charge of the resident’s care.

The attorneys at the Law Offices of Thomas L. Gallivan, PLLC work diligently to protect the rights of nursing home residents.  Please contact us to discuss in the event you have a potential case involving neglect or abuse.

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