Montgomery Place Nursing Center

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for 38 residents who reside in the facility and received their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to prepare and store food in a sanitary manner for 38 residents who received their meals from the kitchen. This deficient practice placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents, with two reviewed for dementia care. Based on observation, record review, and interview, the facility failed to revise one resident, Resident (R) 35's plan of care with individualized person-centered interventions for dementia (a progressive mental disorder characterized by failing memory and confusion). The facility further failed to monitor and document R35's behaviors as directed in his plan of care. This deficient practice placed the resident at risk for decreased quality of life due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents, with two reviewed for dementia care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia (a progressive mental disorder characterized by failing memory and confusion) treatment plan that utilized non-pharmacological approaches to care for one resident, Resident (R) 35. This placed the resident at risk for abuse and decreased quality of life.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the Consultant Pharmacist (CP) failed to identify and report out-of-parameter blood pressures for one resident, Resident (R) 35. This placed the resident at risk for physical decline and medication related complications.

Inspectors wroteThe facility had a census of 38 residents, the sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medications per the physician ordered parameters for one resident, Resident (R) 35. This placed the resident at risk for physical decline and other related complications.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the unsuccessful attempts for non-pharmacological symptom management and risk versus benefit for the continued use for Resident (R) 35's antipsychotic (a class of medication used to treat major mental conditions that cause a break from reality). This placed R35 at risk for unintended side effects relate to psychotropic (alters mood or thought) drug medication.

Inspectors wroteThe facility reported a census of 28 residents. Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility.

Inspectors wroteThe facility reported a census of 28 with 14 selected for review. Based on observation, interview, and record review, the facility failed to maintain an infection control program to help prevent the development and transmission of infections for two sampled residents including; Resident (R)21's urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) with failure to keep the collection device off of the floor, to decrease the risk of developing a urinary tract infection; and R3 with the failure to ensure staff were managing a nebulizer medication delivery kit in a sanitary manner to decrease the risk of developing a respiratory infection.

Inspectors wroteThe facility reported a census of 28 residents with 14 selected for review including two residents reviewed for use of side rails, Resident (R)10 and R4. Based on observation, interview, and record review, the facility failed to perform routine inspections of the bed rails to ensure they met safety standards and were not a risk for resident entrapment. The facility reported 17 residents had a rail or other assistive device on the bed.

Inspectors wroteThe facility reported a census of 28 residents with fourteen selected for review. Based on observation, interview, and record review, the facility failed to review and revise the care plan for three of the residents sampled, Resident (R)7 for use of foot pedals to the wheelchair; R10 and R4 for the type of side rails used on the beds.

Inspectors wroteThe facility reported a census of 28 residents with 14 residents sampled, including one resident reviewed for discharge. Based on observation, interview, and record review, the facility failed to complete a discharge summary for the one sampled Resident (R)31, at the time of his discharge from the facility.

Inspectors wroteThe facility reported a census of 28 residents with 14 residents sampled, including six residents reviewed for accidents. Based on observation, interview and record review, the facility failed to safely propel one of the six residents, while in his wheelchair, Resident (R)7.

Inspectors wroteThe facility reported a census of 28 residents with 14 selected for review including one reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to ensure Resident (R)4's oxygen concentrator was clean, and failed to ensure the oxygen tubing storage bag, oxygen tubing, and humidifier bottle were changed per physician orders, to prevent respiratory infections for this resident that required oxygen use.

Inspectors wroteThe facility reported a census of 28 residents with 14 selected for review, including two reviewed for use of bed rails. Based on observation, interview, and record review, the facility failed to complete a side rail assessment for one of the two residents sampled, Resident (R)10, increasing the risk of injury or entrapment (when caught, trapped, or entangled in the space in or about the bed rail).

Inspectors wroteThe facility reported a census of 28 residents with 14 selected for review including five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to provide physician ordered medication when needed for constipation (difficulty passing stools) for one of the five residents, Resident (R)24, to ensure no unnecessary medication usage adverse reactions.