MONTGOMERY PLACE
Non profit - Corporation
40 Beds
Independent
Data: November 2025
Trust Grade
40/100
#267 of 665 in IL
Photo by Montgomery Place Retirement Community
Photo by Montgomery Place Retirement Community
Photo by Montgomery Place Retirement Community
1 / 5 photos
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Montgomery Place has a Trust Grade of D, indicating below-average quality and some significant concerns for residents. It ranks #267 out of 665 facilities in Illinois, placing it in the top half, while locally it ranks #82 of 201 in Cook County, meaning there are better options nearby. The facility is showing improvement, having reduced issues from 14 in 2024 to just 2 in 2025, but still has a concerning $51,632 in fines, which is higher than 76% of Illinois facilities. Staffing is a strength with a 4/5 rating, although turnover is average at 56%. However, there have been serious incidents, including a medication error that led to hospitalization and failures in RN staffing on weekends that could impact resident care. Additionally, there were significant concerns regarding food safety and hygiene practices in the kitchen, which could affect residents' health.
- Trust Score
- D
- In Illinois
- #267/665
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $51,632 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 50 minutes of Registered Nurse (RN) attention daily — more than average for Illinois. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Top 40%
Needs review
14 → 2 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 14 issues
2025: 2 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Illinois average (2.5)
Meets federal standards, typical of most facilities
Staff Turnover: 56%
Near Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $51,632
Above median ($33,413)
Moderate penalties - review what triggered them
Staff turnover is elevated (56%)
8 points above Illinois average of 48%
The Ugly 30 deficiencies on record
1 actual harm
Aug 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
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 review of records and interviews the facility failed provide ostomy plan of care to 1 out of 4 residents (R1) reviewed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interviews the facility failed provide ostomy plan of care to 1 out of 4 residents (R1) reviewed for person centered care plan. This failure is not in accordance with professional standards guidelines. And has a potential to affect 1 resident (R1) ostomy quality of care needs.Findings include: R1 is [AGE] years old, initial admission date 05/11/2024. R1 was seen able to express clearly her thoughts during conversation. On 08/05/2025 at 10:55 AM, R1 stated that V3 (Registered Nurse/Agency) came to her room took her ostomy supplies and ran out of her room. At 12:18 PM, V1 (Administrator) clarified that R1 went for an appointment for her ostomy and came back with change or new ostomy size. After ostomy supplies for new size were used. R1 does not want to use her old ostomy supplies although R1 kept on asking for her ostomy to be changed multiple times a day. V1 stated that Medicare Part B will not cover premature order of supplies. Per V1, R1 was informed that she can go to the hospital to put the ostomy size she like but she refused. V1 said, The main problem was that her new size was run out and Medicare Part B will not cover if the supply does not last that long. And she refuses to use the old size. At 01:22 PM with V2 (Director of Nursing), V2 confirmed that R1's urostomy size was changed after appointment. V2 said, It took a lot of people to calm her down. We told her that new ones need to be ordered. V2 reviewed electronic health record of R1 full care plan. After review V2 cannot find care plan related to ostomy care. V2 said, We have missed it. V2 confirmed that R1 kept on asking her ostomy to be change not as scheduled. Per physician order dated 05/14/2025 ostomy (urostomy) needs to be changed on Monday and Friday one time a day. V2 stated that urostomy care plan needs to be in place and care plan needs to be reviewed quarterly. R1's MDS assessment dated [DATE] under Section H documents that R1 has ostomy. Per CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2017: Care plan should be individualized, and resident centered. Planning of care requires implementing appropriate, individualized interventions and modifying them as appropriate.
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident right to receive services in the facility with r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident right to receive services in the facility with reasonable accommodation of resident's needs in 1 (R1) of 3 residents in a sample of 8.
Findings include:
R1 is a [AGE] year old male with a diagnosis including Heart Failure, Obesity and Multiple Myeloma. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview for Mental Status) 10/15, moderate cognitive impairment.
On 4/28/25 at 12:30PM R1 stated they run out of the proper size diapers for me on the weekends and night shift. The CNAs put a small size diaper on me, and it is very uncomfortable. My wife had to go to the store on several occasions to buy the right size diaper for me to wear. This has happened several times. The CNAs just say they are out of the extra large size.
On 4/28/25 at 12:50PM V6 (family member) stated two times I had to buy diapers for R1 because they ran out of size 3XL. The CNAs used the diapers I purchased.
On 4/28/25 at 12:41PM V5 (CNA, per phone) stated yes last night I took care of R1. We did not have the 3XL diapers needed for R1. I had to put a 2XL on him instead. I am not aware of any supply in the basement for diapers. I was never told that. I have had other instances where R1's wife had to go buy diapers for him because we didn't have the correct size.
On 4/28/25 at 12:35PM V4 (CNA, per phone) stated on last Saturday I ran out of 3XL size diapers for R1. I had to use 2XL size. I ran to the basement and they did not have 3XL diapers for him.
Facility resident concern form dated 4/21/25 shows including statement, He was also told that 3X depends are not available. Concern/Follow-up /Resolution includes statement I explained to the resident that clean linen is always available it is located in another location and staff should have escalated to supervisors for location. This includes 3X depends, security should be called to open basement storage.
On 4/29/25 at 10:50AM V2 (DON) stated I addressed the issue of the concern that R1 was given the wrong size diapers. I had to explain to the CNAs that if they run out of diapers on the floor that they are to notify security. Security will open the basement storage room to retrieve the diapers. The staff failed to do this and that is the reason they say there is no supply.
Nov 2024
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to determine, establish, obtain or discuss code status of 1 (R133) out of 4 residents reviewed for Advance Directives in a sample of 15.
The fi...
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Based on interview and record review the facility failed to determine, establish, obtain or discuss code status of 1 (R133) out of 4 residents reviewed for Advance Directives in a sample of 15.
The findings include:
R133's admission record showed admission date on 11/6/2024 with diagnoses not limited to Unspecified displaced fracture of sixth cervical vertebra,Unspecified fracture of first thoracic vertebra, Fall on same level, Unspecified abnormalities of gait and mobility, Problem related to care provider dependency, Encounter for other orthopedic aftercare, Muscle weakness (generalized), Unsteadiness on feet, History of falling, Obesity.
MDS (Minimum Data Set) dated 11/12/2024 showed R133 with intact cognition.
At 10:09am V2 (DON / Director of Nursing) stated she started working in the facility March 2024. V2 stated residents should have an advance directive / code status ordered or documented in resident's record whether a DNR (Do Not Resuscitate) or Full code and should be care planned. Resident's code status is important during an emergency. The care plan serves as a guidance for the care of the resident that includes plan / goal and interventions and identified problem / concerns of the residents. If there is no care plan, there could potentially be missed opportunities of interventions.
At 11:18 AM V17 (Social Services / SS) stated Advance directives would include code status, end of life issues and choices whether DNR or Full code. Code status is very important to know what the resident wishes are especially during emergency and staff would know what to follow whether to resuscitate or not. V17 stated not sure who should do the care plan for advance directives or code status. Reviewed R133's health record, not able to find order or documentation regarding code status.
Reviewed R133's order summary report dated 11/13/24, no order found for advance directive / code status. Care plan reviewed, none found for code status or advance directives.
Facility was not able to provide documentation regarding R133's code status or advance directives.
Facility's Advance directive policy and procedure dated 5/5/24 documented in part: During the admission process the SS or designee will discuss with each resident and / or the person accompanying the resident the following: Whether they have an advance directives such as a health care surrogate designation, living will or durable power of attorney. Whether they have a Do not resuscitate form. SS or the appropriate designee should visit the resident and discuss advance directives with them to ensure that he / she has executed the advance directives that he / she would want. All residents who wish to have resuscitation withheld should have a physician's order in their medical record. In the event that a resident experiences cardiopulmonary arrest the nurse on duty shall immediately determine the resident's status as a code or no-code.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to electronically transmit MDS (Minimum Data Set) records to CMS system using the CMS-specified Resident Assessment Instrument (RAI) process w...
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Based on interview and record review, the facility failed to electronically transmit MDS (Minimum Data Set) records to CMS system using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 1 (R18) of 1 resident reviewed for resident assessment in a sample of 15.
The findings include:
R18's admission record showed admission date on 6/21/22 with diagnoses not limited to Malignant neoplasm of prostate, Spinal stenosis, Anemia, Atherosclerosis, Chronic kidney disease, Essential hypertension.
R18's Quarterly MDS (Minimum Data Set) ARD (Assessment Reference Date) 10/4/24 was completed on 10/14/24. Final validation report dated 11/11/24 showed record submitted late. The submission date is more than 14 days after the completion date.
On 11/14/24 at 9:50 AM V19 (MDS manager) stated they are an outside company hired by facility and completing some sections of the MDS. V19 stated she is working remotely and coordinating with V2 (DON / Director of Nursing) to let her know what needs to be done for MDS completion. She said the MDS assessment is a comprehensive assessment that shows the need of the residents to develop the comprehensive CP / care plan and they are following RAI (Resident Assessment Instrument) MANUAL for policy and procedures in completing and transmitting MDS assessment. She said Quarterly MDS assessment should be completed 14 days from the ARD and transmitted 14 days from completion date. Stated transmission of MDS should be within the regulatory timeframes. If MDS assessment was transmitted late, it would mean that facility was not following regulation set by RAI manual or not following regulatory timeframes. Reviewed R18 Quarterly MDS ARD 10/4/24 with V19 and stated it was a late transmission. Completion date was 10/14/24, it should have been submitted / transmitted to CMS system on 10/28/24, 14 days from completion date. Per record, R18's MDS assessment was submitted / transmitted on 11/11/24, it was a late transmission and not following regulations.
At 10:09 AM V2 (DON) stated the facility is Following RAI manual for MDS completion and transmission. They have outside company completing some of the MDS sections and transmitting MDS assessments.
Facility's policy RAI OBRA - required assessment summary page 2-18 documented in part: Quarterly transmission date no later than MDS completion date + 14 calendar days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow dietary recommendation and physician order to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow dietary recommendation and physician order to ensure nutritional supplement was provided to a resident with weight loss for one (R3) out of two residents reviewed for nutrition in a final sample of 28.
Findings Include:
On 11/12/24 at 11:30 AM, R3's electronic health records were reviewed. R3's Minimum Data Set, dated [DATE] shows R3 has severely impaired cognition. R3's physician orders have an order for Magic Cup two times a day for supplement Magic Cup or similar product w/L + D (ordered 3/21/2024) and Regular diet, Regular texture, Regular/Thin consistency (ordered 3/15/2022). R3's weight records documented the following weights: 153.2 pounds (lbs) on 11/5/24, 155 lbs on 8/15/24, 157.8 lbs on 7/17/24, and 159 lbs on 6/14/24. There were no weights recorded for the months of September and October. R3's progress notes documented by V7 (Registered Dietitian/RD) reads in part: continue magic cup with lunch and dinner; provides 580 kcal (kilocalorie) and 18 grams protein a day to help meet estimated needs. R3's dietary care plan dated 5/24/24 shows R3 triggered for significant weight loss and magic cup was added at lunch and dinner.
On 11/12/24 at 12:33 PM, R3 was eating lunch in R3 room. R3's lunch tray consisted of corned beef sandwich, zucchini, minestrone soup, a can of cola, and a glass of water. R3's meal ticket does not indicate R3's magic cup for lunch and dinner. When asked if R3 likes to eat some type of ice cream or pudding, R3 answered, Yes I do.
At 12:44 PM, Surveyor followed up with V20 (Dietary Aide) if the kitchen will be sending the magic cup. V20 stated, We don't have magic cup or ice cream. Some residents they ask but I guess they don't get them.
At 12:56 PM, R3 ate approximately 25% of R3's lunch. R3 did not get the magic cup or other similar product.
At 12:59 PM, V9 (Power of Attorney/Daughter) entered R3's room and was interviewed. V9 stated, She's [R3] lost a lot of weight. I spoke with some people about it. They put [R3] on dietary supplement. [R3] likes to eat sweet stuff. [R3] has ensure and the ice cream. They should be giving those to [R3].
At 1:17 PM, Surveyor came down to the kitchen and asked V6 (Support Chef) if the kitchen has magic cup or similar product. V6 stated that the facility has no magic cup in stock and only has ice cream. V6 stated, As far as I know no one needs the magic cup right now.
On 11/13/24 at 10:40 AM, interviewed V3 (Director of Dining Services) and stated that the facility has no magic cup. V3 stated if there is an order for magic cup the kitchen staff would place it on the resident's tray and should follow what's on the meal ticket and the doctor's order. V3 stated nutritional supplements like magic cup would add some calories to address weight loss. V3 stated that currently, the facility is updating the diet cards manually and new orders such as supplements or diets are communicated to the kitchen verbally or via email.
On 11/13/24 at 1:05 PM, a phone interview was conducted with V7 (RD). V7 stated that nutritional supplements should be given as ordered. V7 stated that R3 should be getting the magic cup for nutritional supplement with lunch and dinner. V7 stated magic cup is a nutritional supplement that provides more calories and protein to help maintain R3's weight. V7 stated that the kitchen should be providing the magic cup to the residents.
The facility's Receiving Orders Policy dated 6/20/24 documents in part: Nurses and other clinical staff will implement and follow the providers orders unless the orders conflicts with safety concerns that may result in resident harm.
The facility's Nourishment and Supplement Policy dated 7/10/24 documents in part: The director of dining services or designee will maintain nourishment and/or supplement lists, using written orders and individual requests as a guide. Assigned food and nutrition services staff will prepare nourishments and supplements according to the nourishment and/or supplement lists. All high protein/high calorie supplements, special nourishments, and other nourishments/supplements that have been ordered by a physician or designee will be individually wrapped, labeled and dated and include the patient's/resident's last name and room number for delivery.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility:
1.
Failed to date and store oxygen tubing in a plastic bag...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility:
1.
Failed to date and store oxygen tubing in a plastic bag when not in use for 1 (R15) resident.
2.
Failed to date and label nebulizer mask for 1 (R26) resident.
These failures could potentially affect 2 (R15, and R26) residents in a sample of 15.
Findings Include:
1. R15's electronic medical record (EMR) revealed R15 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: Respiratory failure unspecified with hypoxia, essential hypertension, and chronic kidney disease.
2. R26's electronic medical record (EMR) revealed R26 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: Chronic obstructive pulmonary disease with acute exacerbation, essential hypertension, and nontraumatic intracerebral hemorrhage in hemisphere subcortical.
On 11/12/24 at 11:35 AM, R15 received in bed, oxygen tubing hanging on the oxygen tank, not dated and not inside a plastic bag when not in use. R15 stated R15 uses oxygen daily.
On 11/12/24 at 11:45 AM, R26 received in bed, nebulizer mask undated by R26's bed side.
On 11/12/24 at 2:58 PM, V8 (Licensed Practical Nurse/LPN) stated V8 has been in the facility for 8 months and V8 is not sure when the oxygen tubing and nebulizer mask should be changed and stored. V8 stated that V8 does not know the policy of the facility regarding nebulizer and oxygen tubing storage.
On 11/12/24 at 3:00 PM, surveyor and V2(Director of Nursing/Infection Prevention) entered R15, and R26's room. V2 stated the oxygen tubing is not dated, not stored in a plastic when not in use, and nebulizer mask is not dated. V2 stated when the oxygen/nebulizer mask tubing is not dated, the staff will not know when the tubing was changed and that can increase the risk of infection for the resident. V2 stated Nebulizing mask/tubing, and oxygen tubing should be changed weekly and as needed and dated to prevent respiratory infection. When the oxygen is not in use, the tubing should be stored in a clean plastic bag to prevent infection.
Facility Policy titled, Oxygen/Nebulizer Care and Storage Policy dated 04/10/2024 documents in part: Date tubing when new tubing is applied. Keep tubing in a clean bag (container) when not in use. Date tubing (mask).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure menu was followed for a resident (R9) receiving...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure menu was followed for a resident (R9) receiving a mechanical soft diet and failed to ensure standardized recipes were followed during pureed food preparation. This failure has the potential to affect 2 residents on pureed diet (R1, R32) out of 26 receiving foods prepared in the facility's kitchen.
Findings Include:
On 11/12/24 at 12:36 PM, V24 (Certified Nursing Assistant) was feeding R9 for lunch. Observed R9 receive a glass of juice, apple sauce, mashed potatoes, ground corned beef sandwich, chicken noodle soup, ground zucchini, and a glass of water. At 12:54 PM, R9 ate 100% of R9's lunch.
R9's physician orders with active orders as of 11/13/24 show a diet order of NAS (No Added Salt) Mechanical Soft Texture, Regular/Thin consistency (order date 3/16/22). R9's Minimum Data Set, dated [DATE] shows R9 is cognitively impaired. The facility's menu spreadsheet for August 2024 - Week 3 Mechanical Soft indicates minestrone soup, ground grilled corn beef sandwich, basil roasted zucchini, and blueberry buckle.
On 11/13/24 at 11:06 AM, during pureed meal preparation observed V6 (Support Chef) added 3 pieces of quinoa stuffed peppers and 3 scoops of sauce in the blender to puree the quinoa stuffed peppers. V6 stated the scoop used had no measurement. Surveyor observed the consistency of pureed quinoa stuffed peppers to be thin. Surveyor asked V6 what [V6] thinks of the consistency of the pureed item. V6 stated, It's a little thin. V6 added more cooked quinoa and blended it together to desired consistency. After rinsing the blender in the sink, Surveyor observed V6 added 6 scoops of boiled baby carrots in the blender to puree the boiled carrots. V6 stated it was about 8 ounces per scoop. Surveyor observed the consistency of pureed carrots to be thin. Surveyor did not observe V6 reading or looking at the pureed quinoa stuffed peppers and buttered carrots recipes before, during or after preparing the pureed quinoa stuffed peppers and buttered carrots.
At 12:46 PM, interviewed V3 (Director of Dining Services). V3 stated that the chef should be following the recipe during pureed food preparation, so it is done properly so the texture is appropriate. V3 stated pureed consistency should have a texture like baby food or is smoother than apple sauce.
On 11/13/24 at 1:05 PM, V7 (Registered Dietician) stated the menus are reviewed by a Registered Dietician for nutritional adequacy. V7 stated menus and recipes should be followed to meet the nutritional calories needed so the residents are getting adequate nutrition per meal. V7 stated residents on pureed and mechanical soft diets should be getting the same menu items as the regular diets except the consistency are different.
Facility recipe titled Quinoa Stuffed Peppers lists ingredients for 48 servings as 47.92 each quinoa stuffed peppers, 1 ¼ quarts stock vegetable, and 2 1/3 cup thickener. Recipe instructions documented in part to chop item in food processor until it reaches a fine grind. Gradually add stock in a thin stream to finely ground product in food processor and continue to process until the product is completely pureed (smooth, no lumps or bits). Gradually add food thickener, fold into food product with a wire or rubber spatula, blend until it develops a smooth mashed potato consistency.
Facility recipe titled Buttered Carrots lists ingredients for 48 servings as 11 pounds 16 ounces buttered carrots, 1 2/3 cup broth vegetable base, 1 2/3 cup melted butter, and 3 1/3 cup thickener. Recipe instructions documented in part to blend vegetables in food processor until smooth. Prepare broth per separate recipe. Gradually add broth and margarine in a thin stream to vegetables; blend until completely pureed, no lumps or bits. Remove from processor, place in a bowl twice the volume of the food product. Gradually add Thickener, fold into product with a wire whip or rubber spatula blend until a smooth Mashed Potato consistency is reached.
The facility's MODIFIED TEXTURE FOODS policy dated 1/24 reads in part: Provide a standardized process for modified texture foods to meet community-approved diet guidelines and to assure palatability, flavor, texture, and nutritional value. The regular diet menu item will be used to prepare all modified-textured menu items unless otherwise indicated by the menu diet spreads. Foods requiring modification to a puree texture will have a smooth texture. Portions of modified-texture menu items will be provided in the proper amounts according to menu diet spreads.
The facility's Diet Type Report printed on 11/13/24 shows there are 2 residents (R1, R32) currently receiving pureed diet texture in the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to develop and implement a comprehensive person...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to develop and implement a comprehensive person-centered care plan to meet preferences and goals and address the resident's needs that include measurable objectives and timeframes for 5 (R6, R17, R21, R22, R29) of 5 residents reviewed for comprehensive care plan in the sample of 15.
The findings include:
R17's admission record showed admission date on 8/30/2024 with diagnoses not limited to Unspecified fracture of shaft of left tibia, Anemia, Spinal stenosis cervical region, Essential (primary) hypertension, Polyosteoarthritis, Pain in left shoulder, Presence of artificial knee joint bilateral, Unspecified fracture of upper end of right tibia, Unspecified glaucoma.
R22's admission record showed admission date on 5/11/2024 with diagnoses not limited to Other nontraumatic intracerebral hemorrhage, Malignant neoplasm of colon, Essential (primary) hypertension, Unspecified convulsions, Malignant neoplasm of bladder, Gastrostomy status, Dysphagia following nontraumatic intracerebral hemorrhage, Hemiplegia unspecified affecting left nondominant side.
R29's admission record showed admission date on 9/1/2024 with diagnoses not limited to Acute respiratory failure with hypoxia, Adult failure to thrive, Suicidal ideations, Pleural effusion, Essential (primary) hypertension, Squamous cell carcinoma of skin of right upper limb, including shoulder, Hyperlipidemia, Iron deficiency anemia, Benign prostatic hyperplasia, Sciatica.
On 11/12/24 At 3:50 PM Reviewed R29's POS (Physician order sheet) showed active order not limited to: DNR (Do Not Resuscitate). No care plan found for advance directives or code status in R29's health record.
On 11/13/24 at 12:55 PM Reviewed R17' POS showed active order not limited to: Full Code. No care plan found for advance directives or code status health record.
On 11/14/24 at 9:10 AM Reviewed R22's physician order and showed active order not limited to Duloxetine HCl Capsule Delayed Release Particles 20 Give 2 capsule by mouth one time a day for depression. No care plan found for use of psychotropic medication use in R22's health record.
At 10:09am V2 (DON / Director of Nursing) stated she started working in the facility March 2024. V2 said care plan should be done or developed by IDT (interdisciplinary team). Care plan serves as a guidance for the care of the resident that includes plan / goal, interventions and identified problem / concerns of the resident. If there is no care plan, could potentially miss opportunities of interventions or progress of the resident in going back to the community. Care plan should be individualized according to resident's needs. Advance directives, high risk meds such as psychotropic and anticoagulant medications and dementia care should be care planned. Reviewed R17, R22 and R29's records no care plan found for advance directives and psychotropic medication use.
At 11:18 AM V17 (Social Services / SS) stated Advance directives would include code status, end of life issues and choices whether DNR or Full code. Code status is very important to know what the resident wishes are especially during emergency and staff would know what to follow whether to resuscitate or not. Stated she is not sure who should do the care plan for advance directives or code status.
MDS (Minimum Data Set) dated 9/5/2024 showed R17 was cognitively intact.
MDS ARD 8/15/2024 showed R22's cognition was moderately impaired.
MDS dated [DATE] showed R29's cognition was moderately impaired.
Facility was not able to provide person-centered comprehensive care plan for advance directives for R17 and R29 and care plan for psychotropic medication use for R22.
Facility's comprehensive care plan policy and procedure dated 7/30/21 documented in part: each resident will have a person-centered comprehensive care plan developed and implemented to meet his / her preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. It includes measurable objectives and timeframes to meet the resident's medical, nursing and mental / psychosocial needs that are identified in the comprehensive assessment.
Facility's policy and procedure for psychotropic dated 8/12/21 documented in part: The resident's comprehensive care plan will reflect the plan for a gradual dose reduction or contraindications for same.
On 11/14/24 at 1:14 PM, R6's clinical records were reviewed and showed an admission date of 6/24/24 with included diagnoses but not limited to Ventricular Tachycardia and Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side. R6's physician orders with active orders as of 11/14/24 shows an order of anticoagulant Warfarin Sodium Oral Tablet 2 MG (Warfarin Sodium) Give 1 tablet by mouth in the afternoon for stroke (order date 11/5/24). R6's Minimum Data Set, dated [DATE] shows anticoagulant was marked. R6's comprehensive care plan does not address R6's anticoagulant medications use.
On 11/14/24 at 12:56 PM, R21's clinical records were reviewed and showed an admission date of 8/16/24 with included diagnosis but not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety. R21's Minimum Data Set, dated [DATE] shows active diagnoses section I marked Non-Alzheimer's Dementia. R21's comprehensive care plans were reviewed and no care plan for dementia was identified.
The facility's Dementia policy dated 5/15/24 documents in part: Care plans and management will be individual and seen from the perspective of the client. Clients Care Plans will reflect diversity, gender, ethnicity, age, religion, sexuality and personal care needs and protected characteristics.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedures by NOT (a) attempt...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedures by NOT (a) attempting to use appropriate alternatives prior to installing a side or bed rail, (b) assessing the resident for risk for entrapment from bed rails prior to installation, (c) reviewing the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation and (d) developing and implementing a comprehensive person-centered care plan for 4 (R1, R17, R29 and R132) out of 4 residents reviewed for accidents and hazards in a sample of 15.
The findings include:
R1's admission record showed admission date on 10/4/2019 with diagnoses not limited to Cerebral infarction, Vascular dementia, other seizures, Essential (primary) hypertension, Unspecified osteoarthritis, anxiety disorder.
R17's admission record showed admission date on 8/30/2024 with diagnoses not limited to Unspecified fracture of shaft of left tibia, Anemia, Spinal stenosis cervical region, Essential (primary) hypertension, Polyosteoarthritis, Pain in left shoulder, Presence of artificial knee joint bilateral, Unspecified fracture of upper end of right tibia, Unspecified glaucoma.
R29's admission record showed admission date on 9/1/2024 with diagnoses not limited to Acute respiratory failure with hypoxia, Adult failure to thrive, Suicidal ideations, Pleural effusion, Essential (primary) hypertension, Squamous cell carcinoma of skin of right upper limb, including shoulder, Hyperlipidemia, Iron deficiency anemia, Benign prostatic hyperplasia, Sciatica.
R132's admission record showed admission date on 10/17/2024 Chronic respiratory failure with hypoxia, Acute on chronic diastolic (congestive) heart failure, Essential (primary) hypertension, Chronic obstructive pulmonary disease, Alzheimer's disease, Hyperlipidemia, Gastro-esophageal reflux disease, Chronic embolism and thrombosis of unspecified deep veins of left lower extremity, Chronic pulmonary embolism, Chronic kidney disease, Unspecified osteoarthritis.
On 11/12/24 at 11:28 AM Observed R132 lying in bed, on moderate high back rest, alert and verbally responsive with confusion, both upper side rails were up.
At 11:31 PM R17 Observed lying in bed, alert and verbally responsive, appears comfortable, well groomed. Stated she has weakness on both lower extremities. Observed both upper side rails were up.
At 11:39 AM Observed R29 sitting up on the side of the bed, alert and verbally responsive, appears comfortable and well groomed. Bed on lowest position, upper side rails were up.
On 11/13/24 12:22 PM Observed R1 lying in bed, nonverbal, head of bed elevated, both upper bed rails were up.
At 12:25 PM Observed R17 lying in bed, both upper side rails were up. V18 (Nursing Supervisor) requested to R17's room and stated side rails are up by staff to promote independence or help with turning and repositioning resident while in bed.
On 11/14/24 at 10:09am V2 (DON / Director of Nursing) started working in the facility March 2024. She said there is no restorative nurse in the facility, she oversees side/ bed rail use. Stated upper side rails are used for residents to help them get out of bed, aid in mobility, turning or repositioning. V2 said use of side rails should be assessed and care planned but not sure if there should be an order for it. If not assessed properly the resident could be harmed by entrapment, risk for harm if side rail not functioning properly, resident could climb over it and risk for accident and hazards. V2 said the care plan should be individualized according to resident's needs. The care plan serves as a guidance for the care of the resident that includes plan/ goal and interventions and identified problem/ concerns of the residents. If there is no care plan, there could potentially be missed opportunities of interventions or progress of the resident. Reviewed R1, R17, R29 and R132's health record with V2, unable to find documentation for care plan, assessment and consent for use of side rails.
MDS (Minimum Data Set) dated 9/13/2024 showed R1 was rarely or never understood. R1 needed total assistance or Dependent with eating, oral, toileting and personal hygiene, shower / bathe self, upper and lower body dressing.
MDS dated [DATE] showed R17 was cognitively intact. R17 needed set up or clean up assistance with eating, supervision or touching assistance with oral hygiene; Partial/ moderate assistance with personal hygiene; Substantial / maximal assistance with shower / bathe self, upper body dressing; Dependent with toileting hygiene, lower body dressing, chair / bed and toilet transfer.
MDS dated [DATE] showed R29's cognition was moderately impaired.
MDS dated [DATE] showed R132's cognition was severely impaired. She needed set up / clean up assistance with eating; Supervision or touching assistance with oral hygiene; Dependent with toileting hygiene, shower / bathe self, upper body dressing, lower body dressing, chair / bed and toilet transfer; Substantial / maximal assistance with personal hygiene.
Reviewed R1, R17, R29 and R132's health record with no order for side rails, no care plan, no assessment found for use of side / bed rails. R1, R17, R29 and R132's record did not show an attempt to use appropriate alternatives prior to installing a side or bed rail.
Facility was not able to provide documents / records regarding care plan, assessment, consent for side rail use for R1, R17, R29 and R132.
Facility's Bed rails policy and procedure dated 10/10/22 documented in part: Bed rails are adjustable metal or rigid plastic bars that attach to the bed. Entrapment is an event in which a resident is caught, trapped, or entangles in the space in or about the bed rail. This facility will attempt to use appropriate alternatives prior to installing a side or bed rail. Assess the resident for risk for entrapment from bed rails prior to installation. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. Documentation in the resident's record will reflect this assessment and related information, including how the alternatives failed to meet the resident's assessed needs. After the installation of bed rails, it is expected that the facility will continue to provide necessary treatment and care, in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's record, and include the following components, but are not limited to: the type of specific direct monitoring and supervision provided during the use of the side rails, including documentation of the monitoring. The identification of how needs will be met during use of the bed rails, such as for repositioning, hydration, meals, use of bathroom and hygiene. Ongoing assessment to ensure that the bed rail is used to meet the resident's needs. Ongoing evaluation of risks.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to account for and dispose of controlled medications ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to account for and dispose of controlled medications in a manner that would decrease the possibility of loss or diversion and failed to dispose expired controlled medication for 1 (R1) resident. These failures could potentially affect 12 residents assigned to the west medication cart as of census dated [DATE].
The findings include:
On [DATE] at 12:07 PM V10 (Licensed Practical Nurse / LPN) stated she has been working in the facility since [DATE]. The west side medication cart was inspected and the controlled medications counted with V10. She said outgoing and incoming nurses are counting the narcotic medications and signing off in the controlled medication sheet after every count. R11's Tramadol with remaining 2 half tablets, blister packet / slots were compromised or broken and had a piece of transparent tape over the back.
At 12:28 PM The west side medication room was inspected with V10 and observed R1's Hydromorphone concentrates about 30ml with Expiration date of [DATE] was kept inside the refrigerator. V10 stated expired medication should be returned to hospice care or should be discarded or wasted because it is expired.
On [DATE] at 10:09am V2 (Director of Nursing / DON) stated she started working in the facility in [DATE]. She said the expiration date for all medications should be checked daily. If expired medication is kept inside the refrigerator, this could potentially be given to the resident and could have an adverse reaction. V2 said, nurses are expected to sign / initial controlled substances record sheet after counting off between shifts, incoming and outgoing nurse should sign to ensure that controlled medications are accounted for. If there are missing signature or initials it could indicate that they are not counting the controlled medications. Stated medication packaging should remain in original packaging, not tampered. V2 said if blister packet or slots for controlled medication like tramadol was tampered or taped, it should be discarded or wasted because you will not know if the medication is correct or has been contaminated. Tampered medication packaging could be a hazard, you don't know if somebody has done something to it. Nurse should get somebody to witness and waste / dispose the medication.
R1's order summary report dated [DATE] showed active order not limited to Hydromorphone oral liquid 4mg/ml every 2 hours as needed for pain / shortness of breath. Give 0.25ml.
R11's Controlled substance proof of use record showed remaining 2 Tramadol 50mg 1/2 tablet. Record indicated if dose is contaminated, lost, broken enter the information under comments.
Reviewed facility's shift change accountability record for controlled substances showed multiple missing nurse's initial or signature on [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE], [DATE], [DATE], [DATE].
Facility record showed the west medication cart assigned to 12 residents as of census dated [DATE].
Facility's controlled substances policy and procedure dated [DATE] documented in part:
This policy provides guidance for controlled substances and their storage, administration, documentation, and disposal. Facility will continue to ensure in complying with all Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Controls and Prevention (CDC) guidance related to controlled substances.
Expired containers of controlled substances (with any contents remaining) must be separated from expired containers of controlled substances and must be clearly labelled as being expired.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to follow their policy by not ensuring that medications are stored in original containers, properly labeled, and separate fro...
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Based on observations, interviews, and record reviews, the facility failed to follow their policy by not ensuring that medications are stored in original containers, properly labeled, and separate from food for one out of 2 medication carts and storage rooms reviewed for the medication storage and labeling. These failures could potentially affect 12 residents assigned to the west medication cart as of census dated 11/12/24.
The findings include:
On 11/12/24 at 12:07 PM V10 (Licensed Practical Nurse / LPN) stated she has been working in the facility since November 2018. [NAME] side medication cart inspected with V10 and found about 20 loose yellow capsules and white tablets inside plastic container covered with tape and with no label, kept inside the narcotic box. V10 unable to determine the name of the medications and for whom they belonged to. V10 stated these loose medications should have been disposed or discarded.
At 12:28 PM the west side medication room inspected with V10. Observed the locked refrigerator with medications such as insulin, flu vaccine, acetaminophen suppositories, hydrocortisone suppositories, Morphine concentrate, Hydromorphone concentrate, Carton of Jevity 1.5 and bottle of ensure were also kept inside the fridge together with multiple medications.
On 11/14/24 at 10:09 AM V2 (Director of Nursing / DON) stated the medications kept inside the refrigerator should be separated from food/ beverages to avoid or prevent possible contamination. V2 said any medications with no proper label should be discarded or disposed. Somebody could give it to the resident unknowingly and it could be a hazard.
Facility record showed the west medication cart assigned to 12 residents as of census dated 11/12/24.
Facility policy and procedure for medication and biological storage dated 7/1/18 documented in part: The community shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. The community will not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs will be returned to the dispensing pharmacy or destroyed. Medications requiring refrigeration must be stored in a refrigerator, medication must be stored separately from food and must be labelled accordingly.
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 interview and record reviews, the facility failed to provide eligible residents and/or resident representatives educati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccination and assess eligibility and offer pneumococcal vaccination to four (R9, R11, R12, and R18) of six residents reviewed for pneumococcal and influenza vaccinations.
Findings Include:
1.R9's electronic medical record (EMR) revealed R9 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: Unspecified Asthma, type 2 diabetes mellitus with diabetic polyneuropathy, other specified disease of pancreas, chronic embolism and thrombosis of unspecified vein, and bullous pemphigoid.
R9's EMR revealed no documentation indicating the facility assessed R9's eligibility to receive the pneumococcal vaccination and/or that R9 was provided education related to the pneumococcal vaccination. There were no signed consents for pneumococcal immunizations found in R9's EMR.
2. R11's EMR revealed R11 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included, but not limited to: cervical disc disorder with myelopathy, spinal stenosis, and anemia.
R11's EMR revealed no documentation indicating the facility assessed R11's eligibility to receive the pneumococcal vaccination and/or that R11 was provided education related to the pneumococcal vaccination. There were no signed consents for pneumococcal immunizations found in R11's EMR.
3. R12's EMR revealed R12 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included, but not limited to: parkinsonism unspecified, cerebral ischemia, adult failure to thrive, and cerebrovascular disease.
R12's EMR revealed no documentation indicating the facility assessed R12's eligibility to receive the pneumococcal vaccination and/or that R12 was provided education related to the pneumococcal vaccination. There were no signed consents for pneumococcal immunization found in R12's EMR.
4. R18's EMR revealed R18 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included, but not limited to: chronic kidney disease, anemia,
essential primary hypertension, malignant neoplasm of prostate, spinal stenosis, and atherosclerotic heart disease of native coronary artery without angina pectoris.
R18's EMR revealed no documentation indicating the facility assessed R18's eligibility to receive the pneumococcal vaccination and/or that R18 was provided education related to the pneumococcal vaccination. There were no signed consents for pneumococcal immunization found in R18's EMR.
The facility's immunization log provided by V2 (Infection Preventionist) on 11/13/24 shows no pneumococcal vaccines provided for R9, R11, R12, and R18.
On 11/14/24 at 10:35 AM, V2 (Infection Preventionist) stated that V2 should obtain consents and provide the residents and/or their family representatives the educations regarding influenza and pneumococcal vaccinations. V2 stated that the education should be in the progress notes in the resident's EMR, and the consents should be uploaded in the EMR. V2 stated that since V2 started in March 2024, V2 have not given any pneumonia vaccines to any resident. V2 stated that V2 has not provided any education or obtain any consents for pneumococcal vaccines since V2 started. V2 stated, V2 is not sure when to order pneumonia vaccine, but V2 will find out from the pharmacy.
The facility's policy titled; Infection Control - Influenza and Pneumococcal Immunizations for Residents reads in part:
Pneumococcal Immunizations:
Before offering the pneumococcal immunization, each resident and or resident representative receives education regarding the benefits and potential side effects of the immunization.
Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized.
Pneumococcal immunization will be offered in accordance with CDC immunization algorithm for PCV13 and PPS23.
The resident's medical record includes documentation that indicates, at a minimum, the following:
That the resident or resident representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure to have a Registered Nurse (RN) staffed 8 hours with a 24 hour period on weekends to care for residents'needs based on the staffing ...
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Based on interview and record review, the facility failed to ensure to have a Registered Nurse (RN) staffed 8 hours with a 24 hour period on weekends to care for residents'needs based on the staffing scheduling and PBJ (Payroll Based Journal) staffing data report. This failure could potentially affect all 28 residents residing in the facility as of census 11/12/24.
The findings include:
On 11/14/24 at 10:40 am V2 (Director of Nursing/DON) stated that it is V2's expectation that there shall be a minimum of one Registered Nurse (RN) on duty in the facility for eight hours, seven days a week. V2 stated that V2 has four RNs and two of the RNs are as needed. V2 stated that V2 does not have a RN on duty some days and weekends especially in the month of April, May, and June, and V2 is interviewing more RNs for this position. V2 stated that the potential problem of not having RNs to take care of residents could result in poor outcomes to residents requiring specialized care that is beyond the scope of the Licensed Practical Nurse (LPN).
On 11/14/24 at 12:15 PM, V1 (Administrator) stated V1 oversees staffing in the facility.
V1 stated that it is V1's expectation that the facility meets the RN eight hours a day, 7 days a week. V1 stated that V1 has 2 nurses each shift and the nurses work 12 hour shifts (7am-7pm shift, and 7pm-7am shift). V1 stated that V1 has not been meeting the 8 hours of RN daily even on 11/11/24 and 11/12/24 and V1 has been utilizing V2 or agency at times, but V1 is looking into hiring more RNs. V1 stated that when there is a complex task like Total Parenteral Nutrition (TPN) that LPNs cannot perform this and it can lead to a delay in care.
Reviewed facility's daily schedule with V1, showed the following:
- On 4/6/24 (Saturday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift.
- On 4/7/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift.
- On 4/20/24 (Saturday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift.
- On 4/21/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift.
- On 5/5/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift.
- On 5/18/24 (Saturday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift.
- On 5/19/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift.
- On 6/9/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift.
- On 6/22/24 (Saturday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift.
- On 6/23/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift.
V1 stated that having eight hours of RN daily, seven days a week including weekends should be maintained to provide adequate care and meet the needs of the resident. V1 stated if RN staffing is not met could potentially affect resident's care.
CMS (Centers for Medicare and Medicaid Services) [NAME] report dated 11/07/24 documented in part: Triggered for no RN Hours.
Facility's Daily Nursing Schedule dated 11/10/24 to 11/15/24 was reviewed. There was no RN scheduled to be working on the floor on 11/11/24 and 11/12/24.
Facility's policy titled; Skilled Nursing Staffing Levels dated 1/1/2024 documented in part: There shall be a minimum of one (1) registered nurse on duty in the facility for eight (8) consecutive hours, seven (7) days a week.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their policy and procedure for food and supp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their policy and procedure for food and supply storage to ensure foods in the walk-in coolers, walk-in freezer and dry storage were properly covered, labeled and dated when they were opened and prepared, and discarded on the discard by date. The facility also failed to ensure kitchen staff was wearing hair restraint while in the kitchen, failed to ensure frozen foods were stored six inches above the floor in the walk-in freezer, failed to obtain temperature checks prior to serving the food to the residents, and failed to sanitize and air dry the blender and lid after staff washed during pureed preparation. These failures have the potential to affect 26 residents in the facility who are receiving oral diet.
Findings Include:
On 11/12/24 at 9:36 AM, during the initial kitchen observation conducted with V3 (Director Dining Services), the following were found in the main cooler for meat and dairy: opened foods with no labels when they were opened/prepared and when to discard such as, canned prunes in the container, two opened jars of low fat cottage cheese, a container of lettuce, a container of chicken salad, a container of olives, a container of coleslaw, a container of pears, a container of grilled chicken, a container of tofu, a container of spring mix lettuce, a container of romaine lettuce, a container of cranberries, a container of nuts, a container of spinach, a container of vanilla pudding, and a bag of Monterey jack cheese. Surveyor and V3 also found unwrapped and unlabeled opened parmesan cheese, an opened box of carrot cake, an opened box of double chocolate cake, an opened box German chocolate cake, and opened shredded mozzarella cheese with an opened date of 10/31/24 and discard by 11/6/24 written on the label. In the dry storage area, there was an opened box of cream of wheat mix that was not wrapped and not labeled with opened date. In the walk-in freezer, there were six boxes of frozen cods, a big box of bread buns, and a container of demi-[NAME] placed on the floor. V3 stated that there should not place anything on the floor per food storage policy and foods should be stored 6 inches about the floor. In the walk-in cooler for produce, Surveyor and V3 found a tray of [NAME] sandwiches not wrapped on the rack and no date when it was prepared, a container of sliced pineapples good thru 11/11/24 on the label, and a container of tomato paste with discard by date of 11/7/24 on the label.
On 11/12/24 at 12:12 PM, food containers were placed on the steam table on the 2nd floor dining area. V20 (Dietary Aide) began serving lunch from the tray line and started plating the food. Surveyor asked for the food temperatures and V20 stated [V20] did not check food temperatures. V20 stated that food temperatures are done in the kitchen.
On 11/12/24 at 1:13 PM, V5 (Cook) was preparing the foods to be served for dinner. V5 had short length hair on V5's head and was not wearing any hair restraint.
On 11/13/24 at 11:06 AM, observed V6 (Support Chef) preparing pureed food for lunch service. When V6 finished pureeing the quinoa stuffed peppers, V6 rinsed the blender and lid in the sink with water. Observed that the blender container was still wet and still with residuals of the pureed quinoa stuffed peppers left inside the blender container. V6 then added 6 servings of 8 ounces boiled baby carrots then pureed in blender.
On 11/13/24 at 10:40 AM, interviewed V3. V3 stated all opened foods are supposed to be properly covered, labeled and discarded by the date written on the labels for food safety. V3 stated expired foods should not be kept stored and should not be served to the residents. V3 stated prepared and opened foods should be completely wrapped, and must be labeled and dated for safety, to maintain freshness, and avoid bacteria. V3 stated, They are not supposed to be storing expired foods. They have to discard expired foods by the discard date. We did the in-service yesterday in regards to labeling, dating, expired foods, and food safety. We're going to be running that daily to train and enforce. They should never serve expired food. If it's opened and unlabeled it should be thrown out. After it's cooked here in the kitchen, they record the temperatures when it's put in the cart and it's taken upstairs and when the diet aide takes it upstairs and put in the steam table, they have to record temperatures in the beginning before serving the food meaning before food is placed on the tray and take temperatures also the end of serving. The temperature log is kept in a binder on each floor. It's important to temp the foods before serving. Hot food should be hot, and cold food should be cold. If it's below the hot of 141 degrees Fahrenheit, we need to reheat it or replace it to prevent bacteria in the food. We don't want it in the danger zone. We have a high-risk population that are prone to sickness. V3 also stated that staff entering the kitchen have to put on the hairnet to keep hair in the head and not on the food.
The facility's MEAL QUALITY AND TEMPERATURE policy dated 1/24 documents in part: When bulk food is transported to a dining serving location, temperatures are taken and recorded in the kitchen before transport as well as at the final serving location. If temperatures are not optimal at the receiving location, corrective action is taken and documented on the taste and temperature log.
The facility's Cook Job Description (undated) documents in part: Maintains basic food recipes, preparation, and service and storage sanitation principles.
The facility's FOOD AND SUPPLY STORAGE policy dated 1/24 documents in part: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain in the safety and wholesomeness of the food for human consumption. Foods past the use by, sell-by, best-by, or enjoy by date should be discarded. Cover, label and date unused portions and open packages. Refrigerated storage: unused portions of canned fruits and vegetables must be transferred to clean, approved storage containers. Label and date container. Frozen storage: store food items 6 inches above the floor, and 18 inches below sprinklers. Wrap food tightly to prevent cross contamination.
The facility's Infection Control - Food Handling (undated) documents in part: Food should be properly labeled and expired foods will be discarded.
The facility's roster dated 11/12/24 documents 28 residents residing in the facility with 2 residents who are NPO (Nothing By Mouth).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure the dumpster was properly covered and not overflowing to prevent the harborage and feeding of pests. This deficient san...
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Based on observation, interview and record review, the facility failed to ensure the dumpster was properly covered and not overflowing to prevent the harborage and feeding of pests. This deficient sanitation practice has the potential to affect all 28 residents residing in the facility.
Findings include:
On 11/12/24 at 9:36 AM, during the initial kitchen observation conducted with V3 (Director Dining Services), observed 3 garbage bins with no covers filled with waste from the kitchen. V3 stated they all should be covered.
On 11/12/24 at 9:55 AM, V3 (Director of Dining Services) brought surveyor outside to inspect the facility's dumpsters. Surveyor observed one dumpster with the lid not fully closed due to overflowing of garbage. V3 stated that all dumpsters should be fully closed to prevent rodents and other pests' infestation.
On At 10:14 AM, V12 (Maintenance Director) that the lids of the dumpster should be closed when not in used so no rodents get in there and no debris would fly out. V12 stated that the lids should be closed for pest control, and if it's open the garbage would attract flies and rodents. V12 stated that it could cause pests in the building because all garbage from the building is being thrown there. V12 stated that if there are too many flies, the flies get in the building.
On 11/14/24 at 10:49 AM, interviewed V13 (Facilities Director) and stated [V13] oversees waste management and environmental services in the facility. V13 stated that the lids of the dumpsters outside the facility should be closed when not in use and should not be overflowing to keep rodents and other pests away from the property. V13 also stated that it is also for the safety of the staff if the lids are not closed items could be tossed and hit staff or the workers.
The facility's SOLID WASTE DISPOSAL policy dated 1/24 documents in part: Garbage containers are clean, lined and covered at all times. Keep lids closed on all outside trash receptacles.
The facility's roster dated 11/12/24 documents 28 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observations, interviews and record reviews, the facility failed to follow their infection control procedures. The facility failed to:
1. Handle linen in a manner to prevent cross contaminat...
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Based on observations, interviews and record reviews, the facility failed to follow their infection control procedures. The facility failed to:
1. Handle linen in a manner to prevent cross contamination.
2. Have measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems.
These failures could potentially affect all 28 residents residing in the facility.
Findings Include:
On 11/12/24 at 12:55 PM, the laundry room was reviewed with V13 (Facilities Director) and V14 (Environmental Services Manager). Surveyor observed V14 and V17 handling clean linens on the folding table without proper hand hygiene. V13 stated V13 should have sanitized V13's hand and wear a pair of gloves before handling clean linens. V14 stated that the policy is to sanitize hands and put on gloves when handling clean linens. V14 stated that touching clean linens with dirty hands can result in cross contamination, spreading of bacteria to residents, and increase the risk for infection.
On 11/12/24 at 1:05 PM, surveyor reviewed the water management area with V13. Surveyor asked V13 for measures in place to prevent the growth of Legionella. V13 stated V13 is not sure, and V13 could not provide any documentation. V13 stated V13 will follow up with V1 (Administrator)
On 11/12/24 at 1:45 PM, V2(Infection Preventionist/IP) stated that staff should sanitize hands before touching clean linens to prevent cross contamination, and the water should be tested yearly for legionella to prevent growing of pathogens.
On 11/13/24 at 9:55 AM, V1(Administrator) stated that Legionella should be checked yearly, and V1 has not checked for Legionella this year. V1 stated that V1 has no record when Legionella was last checked, and it was not checked last year. V1 stated that V1 will call the company to come over later. V1 stated that failure to perform an annual check for Legionella, is a potential for waterborne infection.
The facility could not provide any policy on prevention of Legionella and other opportunistic waterborne pathogens in building water systems.
The facility policy titled Hand Hygiene dated 08/27/2024 documents read in part: Failure to clean contaminated hands can result in the spread of these pathogens to residents, staff, and environmental surfaces.
The facility policy titled Linen Management, documents read in part: Ensure linens are handling in a way to prevent cross contamination and the spread of infection in accordance with State and Federal Regulations, and national guidelines.
The facility policy titled Infection Control, General Policy and Procedure dated 05/05/2024 documents read in part: This policy provides a comprehensive infection control program for distribution to, and by its employees and contractors.
Sept 2023
5 deficiencies
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, interviews and record review, the facility failed to ensure that residents' call devices were within reach. This failure affected 3 out of 28 residents reviewed for call devices ...
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Based on observation, interviews and record review, the facility failed to ensure that residents' call devices were within reach. This failure affected 3 out of 28 residents reviewed for call devices (R3, R4 and R29).
Findings include:
1.) R29's diagnosis includes but not limited to: Chronic pain, Anemia, Type 2 Diabetes Mellitus and Hypertension.
09/18/23 during survey, R29 was observed in bedroom sitting in wheelchair. R29's call device was observed on the opposite side of R29's bed. R29 attempted to retrieve call light but was unsuccessful.
On 9/18/23 at 11:06 AM, R29 said, I cannot reach my call light. Can you please hand it to me?
On 9/18/23 at 11:08 AM, V12 (Licensed Practical Nurse) said, It looks like somebody probably just forgot to put her (R29's) call light back after getting her out of bed. I will move it for her that so she can reach me when she needs me. Surveyor inquired about the importance of having the resident's call device within reach. V12 said, It's good to have the call device within reach just because it is a safety measure for the residents. You never know what they may need, so they (residents) should be able to call for help at any given time.
2.) R3's diagnosis includes but not limited to: History of falling, Anxiety disorder, Abnormality of gait and mobility and overactive bladder.
On 9/18/23 during investigation, R3 was observed in bed awake. R3's call device was observed on the floor. R3 attempted to reach for the call light but could not reach the call light.
On 9/18/23 at 11:33 AM, V4 (Unit Manager) said, R3 cannot reach the call light. I will get it off the floor. It is expected that all resident's call devices are within reach of the resident.
3.) R4's diagnosis includes but not limited to: Major depressive disorder, Osteomyelitis, Pressure ulcer and malignant neoplasm of colon.
On 9/18/23, during investigation, R4 was observed lying in bed. R4's call device was observed wrapped around the bed side rail, out of reach of resident.
On 9/18/23 at 11:50 AM, V8 (Certified Nurse Assistant) said, R4 can't reach the call light. If R4 needs help, R4 can ask her roommate to get help for her. If R4's roommate is not available, I don't know.
Facility policy titled Resident Call System documents, ensure that residents have a means of direct communication between the resident and his/her caregivers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to maintain shift change accountability records for controlled substances for residents'-controlled medications. This failure has...
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Based on observation, interview and record review, the facility failed to maintain shift change accountability records for controlled substances for residents'-controlled medications. This failure has the potential to affect all 36 residents on the second floor of the facility.
Findings include:
On 9/18/23 at during the facility's entrance conference, the facility census shows that there are 36 residents on the second floor of the building.
On 9/21/23 at 12:50pm on the second floor during medication storage observation with V5(Licensed Practical Nurse), the shift change accountability record for Controlled Substances on the second floor shows several missing entries of nurses' signatures, interpreted to mean that there were some shifts that no nurse was accountable or responsible for the narcotics on the floor. The missing entries for August 2023 are 8/1/23, 8/4/23, 8/29/23, and 8/30/23. The missing entries for September 2023 are: 9/5/23, 9/12/23, 1/9/23, and 9/16/23.
V5 was asked why some nurses did not sign the records and if they counted the narcotics before taking over from the previous nurse. V5 stated that she sometimes works on another floor.
On 9/21/23 at 12:09pm, V2(Director of Nursing) was interviewed regarding this. V2 stated that her expectation is that every nurse will sign the accountability sheet at the beginning and at the end of their shifts.
Facility's policy titled Routine Reconciliation of Controlled Substances dated 1/1/22 states in part: This policy is set up for routine reconciliation of controlled substances. Facility should routinely reconcile controlled substances stored in medication carts, emergency supplies and should reconcile controlled substances waiting to be destroyed. The reconciliation should be performed by two licensed nurses or a licensed nurse and an authorized licensed healthcare professional. #6.8 states: Both nurses should sign the reconciliation sheet.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation, interviews and record review, the facility failed to ensure that the steam table that hold meals was working properly. This failure affected two residents, R26 and R32 who stated...
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Based on observation, interviews and record review, the facility failed to ensure that the steam table that hold meals was working properly. This failure affected two residents, R26 and R32 who stated that the food served was not at the preferred temperature and has the potential to affect all 36 residents that reside on that unit and receive meals from the steam table.
Findings include:
1.) R32's diagnosis includes but not limited to: Muscle weakness, Chronic Kidney Disease, Vitamin D deficiency, Anemia and Prediabetes.
R32 has a BIMS (Brief Interview for Mental Status) score of 13, which indicates cognitively intact.
On 9/18/2023 at 11:15 AM R32 was observed on second floor near the Nurse's station. Surveyor inquired about R32's care. R32 said, I am ok. The food that they give us could be a little warmer. Often times, I have to ask staff to warm my food up for me.
2.) R26's diagnosis includes but not limited to: Anxiety disorder, Malignant Neoplasm of Overlapping sites of urinary organs, Hypertension and Constipation.
R26 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact.
On 9/18/23 at 11:42 AM R26 was observed lying in bed with V6 (R26's caretaker) sitting at the bedside. R26 said, The food is ok but is sometimes cold. I have to ask staff to warm it up often or I will have my caretaker warm it up.
On 9/18/23 at 11:42 AM, V6 said, I am here three days per week. R6 asks me to warm his food up at least once or twice per week.
On 9/18/23 at 12:35 PM, Surveyor observed meal cart with 6 room trays. Staff began setting up the room trays with soup at that time (12:35 PM). Dietary staff were observed serving residents in the dining room and making room trays (alternating between the two tasks).
The room trays were complete and taken from dining area via cart at 12:53 PM by V21 (Dietary Aide) to be delivered to residents' rooms.
Surveyor inquired about the temperature on one of the meal trays.
On 9/18/23 at 12:35 PM, V9 (Dietary Aide) took the temperature of a serving of spaghetti on a resident's tray. The thermometer read, 49 degrees Fahrenheit for the spaghetti. At that time, V11 (Dietary Manager) said, The thermometers are new. I don't know why they are not working properly, but the temperatures are not correct.
On 9/18/23 at 12:37 PM, V9 said, The steam table is broken. Only one of the three wells work on the steam table. We do that best we can, but it is hard to keep everything warm with only one working well.
Surveyor observed steam coming from one well on the steam table and the other two wells did not have steam coming from them. All three wells had pans of food in them.
On 9/18/23 at 12:40 PM, V11 (Dietary Manager) said, I put in a work order for the steam table. There is only one well working on the steam table.
On 9/20/23 during investigation, Surveyor asked if all residents were served from the steam table.
On 9/20/23 at 12:15 PM, V10 (Dietary Aide) said, All food come up from the kitchen on a hot box between 12:00 PM and 12:15 PM. Once the food is sent up, we transfer the food to the steam table to be served. We serve room trays and from the steam table and trays for residents in the dining room.
On 9/20/23 at 10:20 AM, V11 (Dietary Manager) said, The steam table is not repaired as of today. I put in a work order last month and believe we are waiting on parts.
On 9/20/23 2:38 PM, V1 (Administrator) said, I am aware of the steam table not working properly. We are waiting on parts for it to be repaired.
Facility policy titled Infection control- Food Handling documents, Food is to be held at appropriate temperatures while being served. Monitoring of food temperatures using food thermometer should be performed regularly.
Facility policy titled Food and Nutrition Services- Sanitation and Food Safety documents, to ensure food safety, hot food is cooked to a minimum safe temperature and is held at no lower than 135 degrees Fahrenheit.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
On 9/18/23 during investigation, Surveyor observed staff setting up dining room for lunch in the 2nd floor dining room.
On 9/18/23 at 12:35 PM, Surveyor observed V9 (Dietary Staff) grabbing a handful ...
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On 9/18/23 during investigation, Surveyor observed staff setting up dining room for lunch in the 2nd floor dining room.
On 9/18/23 at 12:35 PM, Surveyor observed V9 (Dietary Staff) grabbing a handful of spaghetti noodles with a gloved hand and placing the noodles on a plate. V9 then grabbed a ladle with the opposite hand to scoop spaghetti sauce on top of the noodles, and finally grabbing plates with the same gloved hand used to pick up the noodles.
V9 was observed repeatedly grabbing spaghetti noodles and plates with the same hand without changing gloves or using a utensil.
Surveyor inquired about the protocol when serving meals.
On 9/18/23 at 12:38 PM, V9 said, We are supposed to use tongs for sanitary purposes. When we touch the food, we should not touch other things without changing gloves.
On 9/18/23 at 12:40 PM, V11 (Dietary Manager) said, Grabbing food with a gloved hand and touching other things could be a hazard. The food can get contaminated. We are expected to pick the spaghetti up with the tongs or another utensil.
Facility policy titled Infection Control- Food Handling documents, Single-use gloves are not to be used for more than one task. Change gloves and perform hand hygiene between tasks.
Based on observation, interview, and record review, the facility failed to date refrigerated food items when opened; failed to ensure that food is not stored on the floor of the walk-in freezer; failed to ensure that dented cans are stored in a designated area; and failed to serve food in a sanitary manner. These failures have the potential to affect all 36 residents receiving oral foods from the facility's kitchen.
Findings include:
On 9/18/23 at 9:40am during the entrance conference, V1(Administrator) presented the facility's census as 36, and that all the residents are on the second floor.
On 9/18/23 between 10:20am and 10:40am during observation in the kitchen with V13(Director of Dining Services), the following refrigerated food items were observed opened in the walk-in cooler without open dates:
A five-pound container low fat cottage cheese that was less than one-quarter full.
A five-pound container of strawberry nonfat yogurt that was one-third full.
A five-pound container of sour cream that was one-quarter full.
V13 was asked why the foods were not labeled with the open dates when they were opened. V13 responded that she knew the foods should have been dated when opened, but was not sure who opened them, but that she could remove them from the walking cooler and toss them.
In the dry storage area, two #10 cans of baked beans (117 ounces each) were observed in the storage shelves with other canned food items. V13 stated that there is no designated separate place for dented cans pick-up because they usually send the dented cans back to the supplier immediately.
In the walk-in freezer, two racks of bread loaves were observed on the floor. V13 stated that the bread should have been put in the shelves and not on the floor. V13 stated that staff will be educated about these.
On 9/19/23 at 10:55am, V14(Executive Chef) stated I was off yesterday and was told you were here. The surveyor explained the above listed observations to V14 and V14 stated that he(V14) would ensure that staff follow the policy.
Facility's policy on Storage of refrigerated foods with latest revision date 2017 states in part that refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality. Refrigerated food is covered, labeled, and dated with a use by date. Opened products that have not been properly sealed and dated are discarded.
Facility's policy on storage of frozen foods with revision date 2017 says and part: Frozen food are placed in the freezer as quickly as possible after receipt. Food is stored 6 inches above the floor.
Facility's policy on storage of dry foods with revision date 2017 states in part: Dented Cans are stored in a designated area to be returned to vendors.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure that the outside dumpster was covered, and failed to ensure that the overflowing garbage on the floor by the dumpster w...
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Based on observation, interview and record review, the facility failed to ensure that the outside dumpster was covered, and failed to ensure that the overflowing garbage on the floor by the dumpster was picked up. This failure has the potential to affect all 36 residents in the facility.
Findings include:
On 9/18/23 at 10:45am during observation of the facility, the outside dumpster was observed to be full of garbage overflowing to the floor and without a lid or cover. On 9/18/23 at 3:55pm, V16 (Director of Facility) was notified. Again on 9/19/23 at 9:30am and at 11am, the outside dumpster was still in the same condition.
On 9/19/23 at 12:33pm, V1(Administrator) was notified that the outside dumpster was left open with garbage overflowing. V1 stated that it's mostly the Dietary Department that puts garbage in the outside dumpster and he(V1) would ensure that the garbage is closed and picked up.
On 9/19/23 at 1:22pm, V16 stated that the outside dumpster had been picked up by the vendor. V16 added I had to talk to the vendor that it was unsightly, and now, the vendor removed it. I can show you the picture.
On 9/20/23 at 9:40am, V1 presented a facility's document titled Trash Removal. This document dated 9/20/23 states that the regular contract pick-ups (recycle and trash) is Tuesdays and Fridays.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their Inventory List, Resident's Personal policy for one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their Inventory List, Resident's Personal policy for one of three residents (R1) reviewed for theft. This failure resulted in money and credit cards being stolen from R1's purse.
Findings include:
Facility's incident report of 5/8/2023 documents in part, CNA (Certified Nurse Assistant) notified Executive Director (V1 Administrator) that patient (R1) requested to meet. (V1) met with (R1) at approximately 8:45 AM on 5/1/2023. (R1) told (V1) that she realized on Sunday evening (4/30/2023) that some cash ($24.00) and her five credit cards were missing from her wallet and purse. (R1) does not remember looking in her wallet since Wednesday, 4/26 at about 12 noon. (R1's) wallet was in her purse-and the purse (was) hanging on the chair next to her bed.
Investigation included a questionnaire being completed by department staff. No significant findings surfaced to help us identify the person that took the money and credit cards. (V1) also met with (R1's) roommate. Other resident interviews were conducted. No useful information was obtained from these interviews.
We identified an Inventory List of Resident Personal Belongings upon admission that did not get completed for (R1) by the CNA or Nurse. This is required per policy to protect the resident('s) personal property and valuable items during their stay at the community.
Investigation found evidence of financial exploitation. This was due to our non-compliance related to not completing the resident's Inventory of Personal Belongings-and then securely storing those valuable items.
On 7/15/2023 at 2:00 PM, V1 (Administrator) said he was informed on 5/1/2023 by a CNA that R1 wanted to speak with him but did not offer any other information. V1 said he spoke with resident, who informed him that she was missing $24 and five credit cards from her purse which she kept at her bedside hanging on a chair. V1 said R1 told him that she realized on 4/30/2023 that the cash and credit cards were missing from her purse; the last time she had looked in her purse was four days earlier. V1 said R1 was reimbursed $24.
On 7/17/2023 at 9:58 AM via telephone, R1 said she discovered money and credit cards missing from her wallet on 4/30/2023. R1 said she reported this to the V1 (Administrator). R1 said she was re-imbursed $24 by V1. R1 also said when she was admitted to the facility, no one asked her about her valuables or inventoried her belongings.
R1's medical record (Face Sheet) documents R1 is an [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Encounter for Surgical Aftercare Following Surgery on the Digestive System, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus Without Complications, and Essential (Primary) Hypertension. R1's MDS (Minimum Data Set, 4/28/2023) documents R1's BIMS (Brief Interview for Mental Status) as 13 or cognitively intact.
On 7/17/2023 at 11:50 AM, V1 said V11 (Agency Licensed Practical Nurse/LPN) and V12 (CNA) were staff responsible for completing R1's inventory list upon admission.
On 7/17/2023 at 11:54 AM, V11 (Agency LPN) said, I did not receive any orientation related to admissions. So, I did what I was instructed to do at other facilities, I gave the inventory list to the CNA (to complete).
V12 (CNA) was not available for interview.
On 7/17/2023 at 1:59 PM, V19 (Registered Nurse) said, the nurse and CNA should complete resident inventory list upon resident's admission.
Concern dated 5/1/2023 documents (R1) voiced concerns of missing funds/wallet. (R1) stated someone had taken her funds $24.00 and credit cards.
Inventory List, Resident's Personal policy (undated) documents in part:
Basic Responsibility-Licensed Nurse Certified Nursing Assistant, Social Service Personnel, Other
Procedure
1. Record all items on the resident's inventory list.
3. Review list of items with resident and/or representative. Ask resident or representative to sign acknowledgement of inventoried items.
4. The individual completing the inventory list is to witness the signature by signing complete name and title.
5. Give a copy of the inventory list to the resident or resident's representative.
10. Document money and valuables left with the resident and/or who accepted responsibility for these items.
Facility's abuse policy and procedure (Page 2, undated) states: Misappropriation of property is the deliberate misplacement, exploitation or wrongful, temporary or permanent, use of a resident's belongings or money without resident's consent.
Jun 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide R2 with the correct medication at discharge. This failure r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide R2 with the correct medication at discharge. This failure resulted in R2 being discharged with another resident's medication, ingesting the incorrect medication, resulting in urinary retention and hospitalization for urinary catheterization. This affected one(R2) of three residents reviewed for discharge.
Findings Include:
Facility Final Investigation Report (dated 06/01/2023) regarding R2 documents in part: R2 was admitted to facility on April 27, 2023, for short-term rehabilitation, and was discharged on May 18,2023. He was alert and oriented x4. R2 had teaching completed upon discharge by agency nurse, patient verbalized understanding. We were notified by physician on June 01,2023 of a medication error with R2 after discharge from our SNF unit. Doctor had some communication with R2's primary care physician at hospital. Information was passed on that R2 received his medication upon discharge, but also two medication cards for another patient. The other medications were Oxybutynin 5mg and Atorvastatin 20mg. R2 took one dose of 5mg Oxybutynin the evening of May 18th. This medication error triggered urinary retention with R2, and he had to be catheterized in the hospital.
R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Cerebral infarction, unspecified, Hemiplegia and Hemiparesis following unspecified Cerebrovascular disease affecting left dominant side, Essential (Primary) Hypertension, Unspecified lack of expected normal physiological development in childhood, Cerebral Infarction due to unspecified occlusion or stenosis of right middle cerebral artery, Muscle Weakness (Generalized).
On 06/14/2023 at 10:32am V3 (Director of Nursing/DON) stated, When R2 discharged from the facility on 05/18/2023, it was an agency nurse who did the discharge education with R2. V4 (agency nurse) is the one who did the medication teaching upon R2's discharge. V4 is the one who packed R2's medications and sent it home with R2 on the day of discharge. From my understanding, R2 was sent home with 2 wrong medications, and was taking the wrong medication at home. R2 was sent home with medication for urinary retention, and R2 did not have anything wrong with his bladder. We had no knowledge that R2 went home with the wrong medication. The facility had no knowledge that this medication error transpired upon discharge from the facility. The facility was notified by R2's physician of this medication error 2 to 3 weeks after R2's discharge from the facility. R2 was sent home with Oxybutynin and Atorvastatin by error. Oxybutynin is for an overactive bladder, and if taken when not needed, can cause urinary retention. The medication, Oxybutynin, causes the bladder to relax, and when taken by error, it can cause urinary retention. When a resident is discharged from the facility, the nurse does the medication reconciliation with the doctor prior to discharge. Then the nurse goes over the medication with the resident, and the nurse sends the resident's medication home with the resident. R2 was sent home with 2 incorrect medications, and from what was reported to us by R2's physician, the medication caused R2 to have urinary retention, and R2 had to go to the hospital, where R2 was catheterized. Since the error occurred upon R2's discharge, I have done in-service, as well as I implemented a new patient discharge form. The form assists the nurse with educating the resident/care giver about discharge medication and follow up appointments. The resident/care giver must sign the form on the bottom, indicating understanding.
On 06/14/2023 at 12:01pm V6 (Licensed Practical Nurse) stated, I have done a discharge with a resident in the facility. When a resident is discharged , the nurse will do a medication reconciliation with the physician. Once the medication reconciliation is done, the nurse will do a medication education with the resident and/or the family. During a discharge, the nurse will educate the resident/family on the medication name and what the mediation is for and what time the medication should be taken. After the medication education is complete, the nurse will pack the medication into a bag and the medication is sent home with the resident. Narcotics are not sent home with the resident. Upon discharge, the nurse has to review the reconciled medication list and compare it to the medication bingo cards on hand to make sure that the correct medication is being sent home with the resident who is discharging from the facility. I go over the appointments that the resident needs to follow up on once the resident is discharged . I answer all the resident's and family questions, and make sure that the instructions and the medications are understood. I make sure that the resident and family understands how and when the medication is supposed to be taken.
On 06/15/2023 at 1:55pm V9 (Physician/Medical Director) stated, R2 was given the wrong medication in error. The correct medication was sent to the pharmacy for R2. The wrong medication was given to R2 in bingo cards at the time R2 was being discharged from the facility. Medication bingo cards for a different patient were sent home with R2, that is the error that occurred. R2 was sent home with Oxybutynin, which were for another resident at the facility. Oxybutynin can cause urinary retention and constipation; all types of anticholinergic symptoms can occur, and this medication was not intended for this patient. R2 was in the hospital emergency room and had to be catheterized with a foley catheter. R2 has prostate enlargement and that can already slow down urine output, and on top of that R2 received Oxybutynin. With R2 having an enlarged prostate and receiving Oxybutynin, this medication blocked urine output and he was not supposed to receive this medication it was given to him in error. R2 was never supposed to be on this medication.
On 06/14/2023 at 1:54pm, V1 (Administrator) informed surveyor that V4 (agency nurse) was out of the country, therefore, not available for an interview.
R2's Progress Note (dated 05/18/2023) documents, Resident alert and oriented x4, discharged home with meds around 10:30am. Patient teaching completed with clear understanding. Stable upon discharge. DON made aware.
Review of R2's Medication Administration Record (dated 05/01/2023 to 05/18/2023) documents that R2 was receiving Atorvastatin Calcium Oral Tablet 80mg 1 tablet at bedtime. The medication administration record indicated that Oxybutynin 5mg was not being administered to R2 while R2 resided at the facility.
Medications-Leave of Absence, Discharge Policy (undated) states: Drugs which have been dispensed for individual resident use and are labeled in accordance with State and Federal law may be furnished to a resident upon his or her discharge provided that: The charge nurse is responsible for documenting medications provided upon discharge in the resident's medical record.
Prevention of Medication Error In-service (dated 06/09/2023) states: Review and verify each medication for correct patient, correct medication, correct dosage, correct route, and correct time against the transfer orders, or medication listed on the transfer documents.
Jul 2022
7 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, interview, and record review, the facility failed to ensure a resident's privacy was maintained by failing to knock on the door and wait for a response prior to entering 2 (R33, ...
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Based on observation, interview, and record review, the facility failed to ensure a resident's privacy was maintained by failing to knock on the door and wait for a response prior to entering 2 (R33, R34) residents' rooms during medication administration.
Findings Include:
On 07/20/22 09:17 AM V5 (Agency Licensed Practical Nurse) entered R34 room without knocking, removed the blood wrist pressure cuff from her (V5) pocket and placed it on R34 wrist.
On 07/20/22 at 09:29 AM V5 (Agency Licensed Practical Nurse) entered R34 room without knocking and administered the medications.
On 07/20/22 at 09:32 AM R34 stated they generally knock on the door before entering the room.
On 07/20/22 at 12:29 PM V5 (Agency Licensed Practical Nurse) stated I am supposed to knock on the residents' door and announce myself before entering. That is a privacy and dignity issue.
On 07/21/22 at 09:42 AM V9 (Registered Nurse) entered R33 room without knocking, R33 was on a bedpan and V9 stated I will be back.
On 07/21/22 at 09:48 AM V9 (Registered Nurse) entered V33 room without knocking, leaving the computer screen open, the medication cart unlocked with the keys hanging from the control substance drawer lock.
On 07/21/22 at 10:06 AM V9 (Registered Nurse) stated before entering a resident room you should knock on the door unless you are balancing 47 cups. If you cannot knock you should announce yourself. That is an issue of privacy and dignity.
On 07/21/22 at 10:21 AM V3 (Director of Nursing) stated staff are supposed to knock on the door, announce themselves and ask for permission to enter before entering the resident room. If staff enter a resident room without knocking that is an issue with privacy. If staff have cups in their hand, they should announce themselves and say good morning the nurse is coming in. The computer screen should be locked or put to sleep when the nurse is away from it. That is an issue with privacy and confidentiality.
Document titled Residents' Rights for People in the Long-Term Care Facilities undated document in part: Facility staff must knock before entering your room.
Policy:
Titled Resident Rights undated document in part: Nursing home residents have patient rights and certain protections under the law. Resident rights usually include: Respect; You have the right to be treated with dignity and respect. Privacy: You have the right to privacy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders by not weighing 2 (R2, R29) out of 2 reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders by not weighing 2 (R2, R29) out of 2 residents reviewed for edema in a sample of 14 residents.
Findings include:
1. R2 was admitted to the facility on [DATE] with primary diagnosis, not limited to, Acute on Chronic Diastolic (Congestive) Heart Failure. R2 has mild cognitive impairment, according to R2's most recent minimum data set (MDS).
R2 physician note dated 07/07/2022 reads: M W F weights. please notify MD if >3lb gain in 24-hour period.
R2 had the following Weights Missing dated:
7/8/22, 7/11/22, 713/22, 7/15/22, 7/18/22
R2's weights for the following dates are as followings:
7/6/2022 23:54
136.6 Lbs (pounds)- Staff member did not correctly subtract the weight of the resident's wheelchair.
4/22/2022 09:52
126.0 Lbs
3/10/2022 18:28
125.8 Lbs
During interview on 07/20/22 11:13 AM R2 stated, I do not know when the last time I was weighed.
07/20/22 11:33 AM R2 observed being weighed by V11 (Dietary Manager) . R2 is 161.2lbs, wheelchair weight will be subtracted. On 07/20/22 at 12:35 PM, R2 re-weighed on standing scale, standing with a walker. R2's weight 114.8lbs.
07/20/22 02:26 PM V2 (Director of Nurses/DON) stated, R2 has a diagnosis of CHF and she needs to be weighed to be monitor for fluid retention. The nurse is responsible for making sure the resident's weights get entered into the computer.
R2 weighed on 07/21/2022. R2 weighed 125lb.
On 07/22/2022 at 11:51 AM, V10 (Nurse Practitioner) stated, residents with congestive heart failure or edema issues need their weights monitored so we know if they are retaining fluid in their bodies.
On 07/20/22 at 11:26 AM V5 (LPN) stated, I do not know if R2 has an order to be weighed on a weekly basis, I will double check R2's order.
On 07/20/22 at 11:37 AM, V8 (RN) stated, R2 does have an order from 07/07/2022 to be weighed Monday, Wednesday, and Friday. The last weight for R2 was on 7/6/2022. R2 has chronic congestive heart failure (CHF). The weights are an indicator of fluid retention.
2. R29 was admitted to the facility on [DATE] with primary diagnosis, not limited to, Polymyalgia Rheumatica and Abnormal Weight Loss. R29 is cognitively intact, according to R2's most recent minimum data set (MDS).
On 07/20/22 at 11:02 AM, R29 stated, I do not know when the last time I was weighed. My feet are swollen.
On 07/20/22 at 11:38 AM, V8 (RN) stated, R29 should be getting weighed every Monday and Wednesday.
On 07/20/22 at 11:58 AM, V8 (RN) stated, R29's last weight was on 7/1/2022. R29's order for weights are to monitor fluid retention.
On 07/20/22 at 02:44 PM, V2 (DON) stated, R29 should be weighed to monitor him for fluid retention.
R29's physician order dated 06/30/2022 reads: Weights Monday, Wednesday one time a day every Mon, Wed for fluid retention.
Record review of R29's weights show missing weights for following dates: 7/4/22, 7/6/22, 7/11/22, 7/13/22, 7/18/22
Record review of R29's weights: On 07/01/2022, R29 weighed 131.8 lbs. On 07/20/2022, the resident weighed 135.2 pounds which is a 2.58 % Gain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to apply ordered heel protector boots for 1 (R12) out 1 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to apply ordered heel protector boots for 1 (R12) out 1 resident reviewed for pressure ulcers in a sample of 14 residents.
Findings include:
R12 was admitted to the facility on [DATE] with diagnosis, not limited to, Pressure Ulcer of Right Heel, Unspecified Stage. R12 has mild cognitive impairment, according to R12's most recent minimum data set (MDS).
R12's care plan with an initiation date of 07/12/2022 reads: R12 has pressure ulcers with risk for further skin breakdown due to impaired mobility/transfers, incontinence, and malnutrition. R12's care plan intervention with an initiation date of 07/11/2022 reads: heel protector boots per order.
R12 physician order dated 07/11/2022 reads: Ensure patient is wearing heel protector boots when in bed or chair.
On 07/19/22 at 11:45 AM, R12 was observed sitting in wheelchair in R12's room. [NAME] socks were observed on R12's feet. No heel protector boots observed on R12's feet.
On 07/20/22 at 11:02 AM, R12 was observed sitting in wheelchair in R12's room. No sock or shoe observed on R12's left foot. [NAME] sock observed on R12's right foot. No heel protector boots observed on R12's feet. R12 stated, I have boots for my feet, but I do not wear them all the time. I do not know when the last time I had the boots on. I do not know where they are. I think they are in my room.
On 07/20/22 at 12:20 PM, V8 (Registered Nurse/RN) searched R12's room and the heel protector boots found in R12's closet.
On 07/20/22 at 12:23 PM, V8 (RN) stated R12 does have heel protector boots for his heels in his room. R12 has a wound on his right heel and the heel protector boots are used to relieve pressure. Sometimes R12 does not want to wear his boots. If R12 refuses to wear his boots it should be documented.
On 07/20/22 at 12:20 PM, V2 (DON) stated if R12 refuses to wear his heel protector boots it should be documented and care planned. R12 has heel protector boots to protect his heels from skin breakdown.
Facility policy titled, Skin and Wound Care Policy, reads: All residents and patients will receive appropriate care to decrease the risk of skin breakdown. For residents who are bed or chair bound consider using a pressure-reducing device.
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, interview and record review the facility failed to ensure oxygen tubing was labeled for 2 (R4, R133) of 3 (R5) reviewed for oxygen therapy in a sample of 14.
Findings Include:
R1...
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Based on observation, interview and record review the facility failed to ensure oxygen tubing was labeled for 2 (R4, R133) of 3 (R5) reviewed for oxygen therapy in a sample of 14.
Findings Include:
R133 was admitted to the facility 07/12/22 with diagnosis not limited to Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Obstructive Sleep Apnea, Heart Failure and Atrial Fibrillation.
On 07/19/22 at 11:54 AM R133 was observed in bed with oxygen at 3 liter per nasal cannula in use. The oxygen tubing was observed without any labeling.
R4 has diagnosis not limited to Acute on Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Dependence on supplemental Oxygen and Primary (Essential) Hypertension.
On 07/19/22 at 12:01 PM R4 was observed in bed with oxygen at 2 liter per nasal cannula in use. The oxygen tubing was observed without any labeling.
On 07/19/22 at 12:07 PM V6 (Agency Registered Nurse) stated I do not know the policy for labeling and dating the oxygen tubing.
On 07/19/22 at 12:37 PM V7 (Unit Coordinator) stated labeling the oxygen tubing is the nurse responsibility. The oxygen tubing is changed every 72 hours and is labeled and dated so they can when it is time for the tubing to be changed.
On 07/20/22 at 12:58 PM V3 (Director of Nursing) stated the oxygen tubing is to be labeled and dated when it is started and changed. The oxygen tubing is changed every 72 hours.
Policy:
Titled Oxygen Administration dated 07/01/18 document in part: The purpose of this procedure is to provide guidelines for safe oxygen administration. Documentation: The date and time that the procedure was performed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a.) medications were labeled after opening b.) s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a.) medications were labeled after opening b.) stored to prevent the potential for cross contamination and c.) discarded when expired in 1 of 2 medication carts and 1 of 2 medication storage rooms being reviewed for medication labeling and storage.
Findings Include:
On [DATE] at 11:28 AM the west medication cart was reviewed with V6 (Agency Registered Nurse). During review of the west medication cart, R133's Symbicort Aerosol 160-4.5 MCG (Microgram)/ACT (Activated Clotting Time), Albuterol Sulfate Aerosol Solution 108 (90 Base) MCG/ACT, R21's Albuterol Sulfate HFA ((Hydrofluoroalkane) 108 (90 Base) and Symbicort Aerosol 80-4.5 and R4's Two Advair 500-50 Diskus, were observed in the medication cart unlabeled with no open date. R133's Idosorb Gel 0.9%, R4's Spiriva 18 MCG Handihaler -30 capsule, R28's Dry Eye Relief eye drops labeled Home Med and R8's Voltaren Gel 1% were observed in the medication drawer not stored in a bag.
On [DATE] at 11:37 AM V6 (Agency Registered Nurse) stated the medications should be stored inside of bags with Identification and dosage written on it to prevent cross contamination.
On [DATE] at 11:46 AM the west medication storage room was reviewed with V6 (Agency Registered Nurse). During review of the west medication storage room two 1000 ml (Milliliter) bottles of Promote with fiber with expiration date 11/21, Milk of Magnesia 16 fluid ounces with expiration date 11/21, Box of 33 Xeroform Occlusive Gauze with expiration date [DATE] and 5% Dextrose and 0.9% Sodium Chloride 1000 ml with expiration date 06/22 were observed in the cabinets. Lispro with open date [DATE] with no name and not in a storage bag, R8's Aspart 100 unit/ml 3 units before meals with and open date of [DATE] and R132's Insulin Glargine Solution100 unit/ml dated [DATE] not in a storage bag were observed in the west medication storage room refrigerator. V6 (Agency Registered Nurse) stated the insulin should be in a bag to precent cross contamination. If the medication does not have a name, we will not know who it belongs to.
On [DATE] at 09:42 AM V9 (Registered Nurse) left the Medication cart keys on top of the medication cart, entered R33 room.
On [DATE] at 09:46 AM V9 (Registered Nurse) proceeded down the hallway to retrieve medications from the Medication dispenser leaving the medication cart keys on top of the medication cart then entered R1 room before returning to the medication cart.
On [DATE] at 09:48 AM V9 (Registered Nurse) returned to the medication cart, unlocked the controlled substance drawer leaving the keys hanging in the lock then stated I have to go on the other side and get Acetaminophen. V9 proceeded down the hallway then returned to the medication cart with a bottle of Acetaminophen. V9 entered V33 room without knocking, leaving the computer screen open, the medication cart unlocked with the keys hanging from the control substance drawer lock.
On [DATE] at 10:06 AM V9 (Registered Nurse) stated the medication cart keys should be on me at all times to safe-guard the integrity of the medications.
On [DATE] at 02:18 PM V3 (Director of Nursing) stated we have never given expired enteral feeding before. If the enteral feeding is expired, it is supposed to be tossed away. I cannot be used because each resident has enteral feeding specific to them. The expired Xeroform gauze should have been tossed. The expired IV (Intravenous) fluid should be discarded. If the expired IV fluid is used it would be a medication error. The inhaler Advair is good for 6 weeks after opening. If the Advair and Diclofenac is out of the storage bag it could cause cross contamination. Spiriva should have an open date. The eye drops not stored in a bag is a potential for contamination. Insulin is house stock and may not have a resident name on it. If the insulin does not have a name on it, it should be tossed. The insulin is good for 28 days after opening. The insulin that was open and dated on [DATE] should have been discarded by [DATE]. If the insulin had been given that is a medication error and could have been less effective. R9 insulin that was not stored in a bag has a potential for cross contamination.
On [DATE] at 03:59 PM V3 (Director of Nursing) stated I called to replace the medications and get the guidelines for the inhalers.
Document titled Inhaled Medications dated 03/20 document in part: Advair Diskus, date the Diskus when removed from the foil pouch and discard on month after removal from the foil pouch. Symbicort Inhalation Aerosol, date after opening the foil pouch. Discard after 3 months. Ventolin HFA Inhalation Aerosol (Albuterol), date after opening the foil pouch and discard after 12 months.
Policy:
Titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles undated document in part 3.3 The community should ensure that all medications and biologicals, including treatment items are securely stored in a locked cabinet/cart or locked medication room, inaccessible by residents and visitors. 4. The community should ensure that medications and biologicals: 4.4 have an expiry date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines; and 4.3 Have not been contaminated or deteriorated. 6. The community should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damage or missing labels. 11. Controlled substance storage: 11.1 The community should ensure that Schedule II-V controlled substances are only accessible to licensed nursing, pharmacy and medical personnel designated by the community. 11.3 The community should ensure that all controlled substances are stored in a manner that maintains their integrity and security. 14. The community should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Applicable law.
Titled Medication Administration undated document in part: 13. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure reusable equipment was cleaned and disinfected between resident use and medications were administered under sanitary con...
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Based on observation, interview and record review the facility failed to ensure reusable equipment was cleaned and disinfected between resident use and medications were administered under sanitary conditions for 3 of 3 (R33, R34 R134) reviewed for medication administration to prevent cross contamination in a sample of 14.
Findings Include:
On 07/20/22 09:17 AM V5 (Agency Licensed Practical Nurse) place a wrist blood pressure cuff in her (V5) pocket. V5 entered R34 room without knocking, removed the blood wrist pressure cuff from her pocket and placed it on R34 wrist.
On 07/20/22 at 09:19 AM V5 (Agency Licensed Practical Nurse) removed the wrist blood pressure cuff from R34 wrist, placed it in her (V5) pocket, exited the room, returned to the medication cart, removed the wrist blood pressure cuff from her (V5) pocket, placed it in the pouch on the medication cart then prepared R34 medications.
On 07/20/22at 09:36 AM V5 (Agency Licensed Practical Nurse) removed the wrist blood pressure cuff from the pouch and placed it in her (V5) pocket.
On 07/20/22 at 09:38 AM V5 (Agency Licensed Practical Nurse) entered the dining room to take R134 blood pressure. V5 removed the wrist blood pressure cuff from her (V5) pocket and placed it on the table.
On 07/20/22 at 09:40 V5 (Agency Licensed Practical Nurse) applied the wrist blood pressure cuff to R134 right wrist then removed and applied it to the left wrist. V5 removed the wrist blood pressure cuff, placed it in her (V5) pocket, exited the dining room and returned to the medication cart to prepare R134 medications.
On 07/20/22 at 12:29 PM V5 (Agency Licensed Practical Nurse) stated I use my personal wrist blood pressure cuff. After taking the blood pressure, I put it in my pocket then put it back in the pouch. I removed it from the pouch to go to the next resident. The wrist blood pressure cuff should be cleaned before and after use. Ideally, I would use sanitizing wipes to clean it after using the wrist blood pressure cuff on each resident to prevent germs and cross contamination.
On 07/21/22 at 09:36 AM V9 (Registered Nurse) was observed standing at the medication cart. V9 removed the bottle of house stock Vitamin B12 from the medication cart, removed the top and poured a tablet into her hand before placing it into the medication cup. V9 continued to prepare R33 medications pushing the pills from the bingo cards into her (V9) hand before placing them in the medication cup. V9 dropped an Acetaminophen tablet on top of the medication cart, picked the tablet up with her (V9) hand and placed it in the medication cup.
On 07/21/22 at 09:48 AM V9 (Registered Nurse) placed the Enoxaparin 40 MG/0.4 ML, Ciprofloxacin-Dexamethasone Suspension 0.3-0.1% and the Insulin Lispro 100 Unit/ML syringe in her pocket then entered V33 room.
On 07/21/22 at 10:06 AM V9 (Registered Nurse) stated medications should be poured directly into the medication cup and not in my hand. I try to do that, but I don't always do it. There is a potential for contamination.
On 07/21/22 at 10:21 AM V3 (Director of Nursing) stated reusable equipment should be cleaned between residents. It can be wiped with alcohol or the bleach wipes and allowed to air dry to avoid cross contamination. That is an infection control issue. Medications should be poured into the medication cup from the bingo card or medication bottle. If the medication is poured into the nurse hand it is contaminated. The nurse should have discarded the medication and gotten another one.
Policy:
Titled Medication Administration undated document in part: 4.a. avoid contact with tablets.
Titled Reusable Equipment Policy undated document in part: to reduce the transmission of microorganisms and prevent cross contamination of infections. The facility is committed to prevent the transmission and cross contamination of infection that can occur as a result of reusable equipment. 1. Nursing staff will use appropriate cleaning agent to sanitize all reusable equipment (E.G (Example) blood pressure, glucometer) before and after each use. 2. The nursing staff will clean the reusable equipment in between patient use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to update the resident record with the correct code status for 3 of 3 (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to update the resident record with the correct code status for 3 of 3 (R9, R23, R28) residents. The facility also failed to enter the code status for 1 (R133) resident reviewed for Advance Directives in a sample of 14.
Findings Include:
R9 was admitted to the facility on [DATE] with diagnosis not limited to Cerebral Ischemia, Concentration Deficit Cognitive Social or Emotional Deficit and Adult Failure to Thrive.
R9 Order Summary Report dated [DATE] - [DATE] document in part: DNR (Do Not Resuscitate) Order status [DATE], End date [DATE].
Initial review on [DATE] of R9 Electronic Medical Record and Face Sheet Advance Directives document in part: DNR. Updated Face Sheet on [DATE] document in part Advance Directives Full Code.
R23 was readmitted to the facility on [DATE] with diagnosis not limited to Unspecified Dementia, Atrial Fibrillation Mild Cognitive Impairment and Cognitive Communication Deficit. Order Summary Report dated [DATE] - [DATE] document in part: Full Code Order date [DATE], End date [DATE]. Order Summary Report dated [DATE] - [DATE] document in part: DNR (Do Not Resuscitate) Order date [DATE]. Do-Not-Resuscitate (DNR) Practitioner Orders For Life Sustaining Treatment (POLST) Form document in part: Do Not Attempt Resuscitation/DNR Selective Treatment dated [DATE].
Initial review on [DATE] of R23 Electronic Medical Record and Face Sheet Advance Directives document in part: Full Code. Updated Face Sheet on [DATE] document in part Advance Directives DNR.
R28 was admitted to the facility on [DATE] with diagnosis not limited to Hemiplegia and Hemiparesis, Chronic Ischemic Heart Disease, Essential (Primary) Hypertension, Malignant Neoplasm of Prostate and Mild Cognitive Impairment. Order Summary Report dated [DATE] - [DATE] document in part: Full Code. Practitioner Orders For Life Sustaining Treatment (POLST) Form document in part: Do Not Attempt Resuscitation/DNR Comfort-Focused Treatment dated [DATE].
Progress note dated [DATE] document in part: Code Status: DNR (POLST [DATE])
Initial review on [DATE] of R28 Electronic Medical Record and Face Sheet Advance Directives document in part: Full Code.
R133 was admitted to the facility [DATE] with diagnosis not limited to Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Obstructive Sleep Apnea, Heart Failure and Atrial Fibrillation. Face Sheet and Order Summary Report dated [DATE] - [DATE] has no documented Code status. Updated Order Summary Report dated [DATE] - [DATE] document in part: Full Code Order date [DATE].
On [DATE] at 12:21 PM V6 (Agency Registered Nurse) stated R133 was admitted to the facility on [DATE]. If R133 was found unresponsive we would do CPR (Cardio-Pulmonary Resuscitation). There is no order for R133 code status, and I do not see it in the computer. V6 (Agency Registered Nurse) checked the computer and stated R9 is a DNR (Do Not Resuscitate), R23 and R28 are Full Codes.
Record review of R133 Physician Order and Care Plan has no document Code status.
On [DATE] at 12:37 PM V7 (Unit Coordinator) stated R133 Code status should be entered upon admission from the hospital. If the residents are not a DNR they are considered a full code. An order should be written and flagged on the resident face sheet. If the resident is a DNR social service come back and label the chart with a sticker indicating DNR. If a resident that is a DNR is treated as a full code that is a liability on our part and an error for resuscitation.
On [DATE] at 12:58 PM V3 (Director of Nursing) stated the Code status is entered when the resident is admitted . The admitting nurse and Supervisor check and reconcile the code status. If there is no code status, then CPR will be initiated. We would do CPR if it were an emergency situation and there is nothing documented to tell us the code status.
On [DATE] 10:47 AM V4 (Social Service Director) stated the Code status process is the nurse get the status from the hospital or if a resident verbalizes, they want an advance directive the POLST (Physician Order for Life Sustaining Treatment) form is filled out and signed by the resident or POA (Power of Attorney). The POLST form is uploaded in the computer and a copy is put in the chart, make sure the nurse is aware, provide the nurse with a copy and the code status is changed in the system. When initially entering the facility, the residents are considered a full code unless we have the POLST form. The Code status is verified by nurse then entered into the computer. There should be an order for R133 code status and in the Electronic Medical Records so anyone that look in the Electronic Medical Records should be able to see the code status. The order is received on admission and should be entered into the Electronic Medical Record. If there is no order and the code status is not in the computer, the resident is considered a full code. Our Nurse Practitioner does catch the code status if the resident is a DNR. If the paperwork from the hospital document the code status and we do not have the POLST form I follow up or if it is brought to my attention that the resident is a DNR. The physicians upon assessment ask the resident if they want to be a DNR. I can check R28 chart. If a resident is a DNR and documented as a Full code that is not good at all. I don't have R28 POLST form on the referral information that I received. That is not good if a resident is a DNR, but we have Full code on the face sheet because we will be doing life sustaining interventions on someone who preference is a DNR. There would be an error in treatment. I just uploaded R23 POLST form in the Electronic Medical Records. R23 was in assistant living and came to us for rehab but is transitioning to Long Term Care. R23 paperwork did not come over with R23 and the paperwork was still in assistant living. I addressed the Code status after it was brought to my attention and when I was looking for the POLST form. R133 should have had an order stating she (R133) is a full code upon admission. R9 does not have a POLST form and should have been listed as a full code and not a DNR. I let them know the order needed to be changed.
On [DATE] at 11:35 AM V4 (Social Service Director) stated R28 is a DNR. I found the POLST form in the paper chart. There was no DNR sticker on R28 chart for a DNR. An orange sticker is placed on the spine of the paper charts for residents that are DNR's. I was not able to find a POLST form for R9
Document titled Residents' Rights for People in the Long-Term Care Facilities document in part: You have the right to make a Durable Power of Attorney for Health Care, Living Will, Declaration for Mental Health or Do Not Resuscitate Order.
Email dated [DATE] document in part: Subject POLST Form. R9 and R133 full code. R23 DNR selective form and R28 Full code no POLST.
Policy:
Titled Advance Directives undated document in part: Advance directives will be respected in accordance with state laws and facility policy. 3. Prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance Directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 5. b. Do No Resuscitate - Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used.
Titled Do Not Resuscitate undated document in part: 4. Do not resuscitate orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. 5. The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives.
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 harm violation(s), $51,632 in fines, Payment denial on record. Review inspection reports carefully.
- • 30 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $51,632 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Montgomery Place's CMS Rating?
CMS assigns MONTGOMERY PLACE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Illinois, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Montgomery Place Staffed?
CMS rates MONTGOMERY PLACE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Montgomery Place?
State health inspectors documented 30 deficiencies at MONTGOMERY PLACE during 2022 to 2025. These included: 1 that caused actual resident harm and 29 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Montgomery Place?
MONTGOMERY PLACE 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 40 certified beds and approximately 35 residents (about 88% occupancy), it is a smaller facility located in CHICAGO, Illinois.
How Does Montgomery Place Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, MONTGOMERY PLACE's overall rating (3 stars) is above the state average of 2.5, staff turnover (56%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Montgomery Place?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Montgomery Place Safe?
Based on CMS inspection data, MONTGOMERY PLACE 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 3-star overall rating and ranks #1 of 100 nursing homes in Illinois. 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 Place Stick Around?
Staff turnover at MONTGOMERY PLACE is high. At 56%, the facility is 10 percentage points above the Illinois average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Montgomery Place Ever Fined?
MONTGOMERY PLACE has been fined $51,632 across 3 penalty actions. This is above the Illinois average of $33,595. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Montgomery Place on Any Federal Watch List?
MONTGOMERY PLACE 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.