Montereau, Inc.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a care plan was developed to address immediate needs of residents for 2 (#1 and #48) of 8 sampled residents reviewed for care plans. The administrator identified 56 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered according to physician orders for 1 (#56) of 1 sampled resident reviewed for timely administration of medications. The administrator identified 56 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide sufficient staff to answer call lights in a timely manner for 1 (#1) of 3 sampled residents reviewed for call light response. The DON identified 46 residents resided at the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were secured for 2 (first floor North treatment cart #2 and second floor South treatment cart #2) of 2 treatment carts observed to be unlocked and unattended. The DON identified six treatment carts and six medication carts in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure appointments were scheduled for a resident for 1 (#1) of 3 sampled residents reviewed for appointments. The DON identified 46 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure nutritional supplements were implemented for the treatment of pressure ulcers for 1 (#3) of 2 sampled residents reviewed for nutritional supplements. The DON identified 20 residents received nutritional supplements.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered at the ordered time for 1 (#1) of 3 sampled residents reviewed for medication administration. The DON identified 46 residents received medications in the facility.

Inspectors wroteOn [DATE], a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor, and intervene for a resident with a history of skin breakdown. The facility failed to accurately identify the status of a resident at high risk for skin breakdown, failed to accurately and timely document the resident's skin condition, failed to accurately care plan, provide, and monitor the success or failure of interventions for the resident's deteriorating skin condition, and failed to communicate the resident's deteriorating skin condition to other disciplines of the resident's care team. Based on record review and interview, the facility failed to assess, monitor, and intervene for 1 (#1) of 7 sampled residents who had pressure ulcers/wounds or were at high risk for the development of pressure ulcers/wounds. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were utilized during indwelling urinary catheter care for two (#4 and #6) of three sampled residents who were reviewed with indwelling urinary catheters. The DON identified eight residents with indwelling urinary catheters and 25 residents on enhanced barrier precautions.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that a resident was treated with dignity and respect for one (#7) of one resident sampled for dignity and respect. The Administrator identified 67 residents resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure residents were offered the choice to formulate an advanced directive for three (#7, 40, and #208) of seven sampled residents whose advance directive acknowledgements were reviewed. The administrator identified 67 residents who resided in the facility.

Inspectors wroteBased on record review, and interview, the facility failed to develop a comprehensive care plan for four(#40, 41, 50, and #111) of seventeen sampled residents reviewed for comprehensive care plan completion. The Administrator identified 67 residents resided in the facility. Findings. A Comprehensive Care Plans policy, undated, read in part, .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . 1. Resident #50 had diagnoses which included cellulitis of abdominal wall and multiple sclerosis. Resident #50 admitted on [DATE], a comprehensive care plan was not completed after admission MDS assessment completed on 05/18/24. On 07/03/24 at 8:15 a.m., MDS Coordinator #1 was asked the facility policy for completion of a comprehensive careplan. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement their abuse policy by immediately reporting abuse for one of three sampled residents reviewed for abuse. The Administrator identified 67 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident food was prepared and served in a sanitary manner. The Resident Census and Conditions of Residents form documented 61 residents received their meals from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to attempt to use appropriate alternatives prior to utilizing a side or bed rail, assess the risk for entrapment, review the risks and benefits of bed rails with the resident or resident representative, and/or obtain informed consent prior to use of bed rails for three (#7, 53, and #120) of seven residents reviewed for accidents. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure assessments accurately reflected the residents' status for two (#26 and #34) of 19 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility.

Inspectors wrote2. Res #27 had diagnoses which included major depression disorder. An Annual assessment, dated 07/20/22 documented the the resident received antidepressant medication. The resident's care plan was reviewed and did not contain a plan of care related to the resident's use of antidepressant medications. A Physician's Order, dated on 02/07/23, documented the resident was taking sertraline (an antidepressant medication) 25 mg, two tablets every day. A Quarterly assessment, dated 04/17/23, documented the resident received antidepressant medication. On 05/17/23 at 9:31 a.m., the resident was observed in her bed watching television. On 05/18/23 at 9:08 a.m., MDS Coordinator #1 stated she was unsure if she developed a care plan related to the resident receiving antidepressant medication. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow the menu for pureed diet and ensure the meals met the nutritional needs of the residents. The Resident Census and Conditions of Residents form documented 11 residents had mechanically altered diets including pureed and all chopped food.

Inspectors wroteBased on record review and interview the facility failed to ensure medical records were readily accessible and systematically organized. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to utilize their antibiotic stewardship policy to monitor antibiotic use for one (#7) of one resident reviewed for antibiotic use. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility.