Mont Marie Rehabilitation & Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) Assessments were accurately coded for two Residents (#52 and #22), out of a total sample of 18 residents. Specifically, the facility failed to:1. For Resident #52, accurately code a pressure injury that was present during the observation look back period and to identify the Resident as being at risk for developing pressure injury.2. For Resident #22, accurately code an identified pressure injury present on admission, when the pressure injury was coded as Stage 3 pressure ulcer and the admission nursing assessment indicated MASD (moisture associated skin disorder) to the sacrum.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide care consistent with professional standards of practice relative to pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for two Residents (#52 and #22), out of a total sample of 26 residents. Specifically, the facility failed to:1. for Resident #52, appropriately identify and communicate a sacral wound observed on admission to the Wound Provider timely, and also failed to implement the Wound Provider interventions for treatment and air mattress use pertaining to the Resident's sacral wound in a timely manner resulting in the sacral wound further deteriorating. 2. [...]

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure that dialysis care consistent with professional standards of practice was provided for one Resident (#11) out of a total sample of 18 residents. Specifically, for Resident #11, the facility failed to:-accurately update the change in access site from the PermCath to the left upper arm fistula (when the Resident had a right chest PermCath and left upper arm fistula [vascular access that is created surgically by connecting an artery and a vein]) for dialysis treatments.-provide ongoing assessment of the patency of the Resident's left upper arm fistula vascular access for thrill (vibration felt) and bruit (swishing sound), to prevent complications related to the vascular access site.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who experienced an acute onset of shortness of breath, and required the administration of supplemental oxygen, the Facility failed to ensure that nursing staff were competent in how to set-up and operate a portable oxygen tank, when nursing were unaware they needed to use a key to open the tanks valve in order to access and administer the oxygen.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose Health Care Proxy had been activated in September 2025, the Facility failed to ensure they maintained Resident #1's rights related to obtaining copies of medical record information, when his/her Health Care Agent (HCA) requested copies of documentation from his/her medical record, and did not receive those copies, in accordance with the regulation.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure they offered assistance in scheduling a Podiatry appointment as requested to ensure good foot health was maintained.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose physician's orders included the administration of multiple medications to help manage his/her specific gastrointestinal diseases, the Facility failed to ensure Resident #1 was provided with nursing care and treatment that met professional standards when the nursing staff failed to administer his/her bowel medications and other medications timely.

Inspectors wroteBased on record reviews and interviews for one of three sampled residents (Resident #1), whose physician's orders included the administration of a medication to manage his/her movement disorder, the Facility failed to ensure he/she was free from significant medication errors, when upon admission, the medication was inaccurately reconciled from his/her Hospital Discharge Summary by nursing and he/she was administered incorrect dosages of the medication for multiple days.

Inspectors wroteBased on interviews, and records reviews, the facility failed to provide appropriate notice of discharge for a facility-initiated discharge, when the Resident did not initiate a request of discharge for one Resident (#72) out of three closed records. Specifically, the facility failed to provide appropriate notice of discharge to Resident #72 when: -the facility determined that the Resident was acting Against Medical Advice (AMA) by driving his/her personal vehicle to a scheduled eye surgery appointment. -the facility notified the Resident he/she was discharged upon return to the facility from the scheduled eye surgery appointment. [...]

Inspectors wroteBased on record review, and interview, the facility failed to provide a written Notice of Intent to Transfer and Discharge to the Resident and/or Resident Representative (RR) and notify the Office of the State Long-Term Care Ombudsman at the time of discharge or shortly thereafter for two Residents (#72 and #34) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #72, provide a written Notice of Intent to Transfer and Discharge and statement of appeal rights as required to the Resident and/or Resident Representative for an unplanned discharge when the facility notified the Resident of the discharge upon his/her return to the facility from a scheduled eye surgery appointment. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure recommendations made by the Behavioral Health Care Team were implemented for one Resident (#53), out of a total sample of 18 residents. Specifically, for Resident #53, the facility failed to ensure an Electrocardiogram (EKG-noninvasive medical test that records the electrical activity of the heart) was completed every six months as recommended by the Behavioral Health Nurse Practitioner.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain appropriate hygiene practices while serving meals in the dining room, on one (3rd Floor Unit) out of three Units observed. Specifically, the facility failed to ensure that nursing staff who were distributing food during the breakfast meal on the 3rd Floor Unit performed appropriate hand hygiene to prevent contamination and the spread of foodborne illnesses.

Inspectors wroteBased on record review and interview the facility failed to accurately complete Minimum Data Set (MDS) Assessments for two Residents (#52 and #60) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #52, accurately code for dental status when the Resident had full upper and lower dentures that were loose fitting. 2. For Resident #60, accurately code for two unhealed pressure ulcers present during the MDS observation period.

Inspectors wroteBased on interview and record review the facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately coded for three Residents (#16, #45, #61) out of a total sample of 19 residents and for one Resident (#71) out of three sampled closed records. Specifically, the facility failed to ensure the MDS Assessment: 1. For Resident #16, was accurately coded relative to the use of a feeding tube. 2. For Resident #45, was accurately coded relative to the use of Oxygen. 3. For Resident #61, was accurately coded relative to pressure ulcers (injury to the skin resulting from prolonged pressure) when the Resident had no pressure ulcers. 4. For Resident #74, was accurately coded relative to the discharge destination when the Resident discharged from the facility.

Inspectors wroteBased on observation, record and policy review, and interview, the facility failed to provide care and services for a suprapubic catheter (an indwelling urinary catheter placed directly into the bladder through the abdomen) for one Resident (#30) out of a total sample of 19 residents, to prevent catheter related complications. Specifically, for Resident #30, the facility staff failed to obtain verification of the Physician's order for the correct size of a suprapubic urinary catheter and ensure that the verified size catheter was in place.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for two Residents (#45 and #278) out of a total sample of 19 residents. Specifically, the facility staff failed to ensure: 1. For Resident #45, that Physician's orders were in place for the use of Oxygen (O2). 2. For Resident #278, that Physician's orders were in place for the use of O2 on admission, and that the appropriate liter per minute (LPM- the amount of supplemental Oxygen someone received through an oxygen delivery device) of Oxygen was administered as ordered by the Physician.

Inspectors wroteBased on record review, and interview, the facility failed to maintain accurate medical records for one Resident (#26) out of a total sample of 19 residents, relative to identifying and documenting the Resident as a falls risk. Specifically, the facility staff failed to ensure that Resident #26's care plan accurately reflected that the Resident was at risk of falling, when the falls care plan was marked as resolved and rendered inactive.