Montgomery Village Care Center

Inspectors wroteBased on record review, and staff interviews, it was determined that the facility failed to properly identify, verify, and document a legally authorized resident representative to exercise the rights of a resident who lacks capacity. This deficient practice was evident for 2 (Resident #8 and Resident #71) of 2 residents reviewed for rights exercised by representative during the annual survey.

Inspectors wroteBased on record review and staff interviews, it was determined the facility failed to ensure consent for psychotropic medications was obtained and maintained in accordance with resident decision-making capacity. This deficient practice was evident for 4 (Resident #4, Resident #5, Resident #3, Resident#8) of 5 residents reviewed for psychotropic medication consent during the annual survey.

Inspectors wroteBased on record review and staff interviews, it was determined that facility staff failed to properly manage care choices for residents in the absence of an advance directive. This deficient practice was evident for 2 (Resident #16 and Resident #4) of 7 residents reviewed for Advance Directives during the annual survey.

Inspectors wroteBased on observation and interviews with facility staff, it was determined that the facility failed to ensure that the environment of resident's care area was kept safe and sanitary. This was evidenced by the paper towel dispenser missing the front cover, which exposed paper towels in the bathroom. This was evident for 2 (Resident #9 and Resident #14) of 160 residents observed during the annual survey.

Inspectors wroteBased on review of resident medical records and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for a resident receiving hemodialysis. This was evident in 1 (Resident #15) of 8 residents reviewed for MDS accuracy during the recertification survey.

Inspectors wroteBased on interviews and record review, it was determined that facility staff failed to ensure residents responsible party were provided care plan meeting invitations and failed to conduct quarterly care plan meetings within the required timeframe. This deficient practice was evident for 2 (Resident #2 and Resident #5) of 3 residents reviewed for care plans during the annual survey.

Inspectors wroteBased on observation, staff interviews, and record review, it was determined that the facility failed to follow professional standards of practice when administering intermittent intravenous (IV) antibiotic infusions. This was evident for 1 (Resident #53) out of 1 resident observed for IV therapy.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that residents' Electronic Health Records (EHR) accurately reflected their cognitive status. This was evident for 2 out of (Resident #11 and #93) out of 7 residents reviewed for advanced directives during the recertification survey.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure the environment was maintained in a manner that minimized the potential spread of infection as evidenced by 1) oxygen tubing was on the floor, 2) foley catheter bag was on the floor, and 3) the laundry area. This was evident for 2 (Resident #1, #17) of 160 residents and the laundry area observed during the annual survey.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that call bells were kept within reach for residents to utilize. This was found to be evident for 8 (Residents #3, #23, #45, #49, #53, #73, #99, and #105) of 44 residents observed on the 4th floor of the facility during the recertification survey.

Inspectors wroteBased on observation and interviews, it was determined that facility nursing staff failed to follow professional standards of nursing practice when administering medications to residents. This was evident for 1 (Resident # 393) of 39 residents during a random observation on the annual survey.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to implement an effective discharge process that adequately prepared Resident # 394 for transition to post-discharge care. This was evidenced by the failure to: 1) develop a discharge care plan for Resident # 394, 2) coordinate the referral to an outside provider for the transition of care, 3) order the recommended medical equipment and 4) provide complete and adequate discharge instructions for Resident # 394. This was evident for 1 (Resident #394) of 39 residents reviewed during the annual survey.

Inspectors wroteBased on review of interviews and record review, it was determined that the facility staff failed to provide a resident with a completed discharge summary upon discharge. This was found to be evident for 1 of 39 residents (Resident #335) that were reviewed during the recertification survey.

Inspectors wroteBased on observation, review of resident medical records and interviews with residents and facility staff, it was determined that the facility failed to ensure that the resident received care to promote the highest practicable wellbeing as evidenced by failure to monitor the resident's mood state after an assessment was completed. This was evident for 1 of 39 residents (Resident # 124) that were reviewed during the survey.

Inspectors wroteBased on observations, record reviews, and staff interviews, it was determined that the facility failed to develop an effective method to determine when the oxygen tubing needed replacing. This was found to be evident for 7(Residents #45 # 71, #73, #83, #96, # 107,# 437) of 7 residents reviewed for respiratory care during the annual survey.

Inspectors wroteBased on observations, family and staff interviews, and record reviews, it was determined that the facility failed to provide supervision for a resident with significant weight loss. This was found to be evident for 1 (Resident # 66) out of 1 resident reviewed for weight loss.

Inspectors wroteBased on observation of the medication carts on unit 1 and unit 3 and interviews with facility staff it was determined that the facility failed to ensure that medications were stored appropriately, and that wasted medication was disposed of properly. This was evident with 3 out of 4 medication carts reviewed during the medication storage facility task.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to maintain an accurate wound treatment order for a pressure ulcer. This was evident for 1 (Resident #56) of 39 residents reviewed during this annual survey.

Inspectors wroteBased on observation and interviews, the facility failed to provide safe, functioning equipment in the shower room. This was found to be evident for 1 out of 6 shower chairs observed in the 2nd floor shower room.

Inspectors wroteBased on surveyor review of clinical records and staff interviews, it was determined that the facility staff failed to implement a resident's wishes as stated in an advance directive, and failed to verify the authority of a medical decision maker on a Maryland Medical Orders for Life-Sustaining (MOLST) form. This finding was evident for 1 of 3 residents reviewed for advance directive care area (Resident #72).

Inspectors wroteBased on medical record review, resident interview and staff interview, it was determined that the facility staff failed to maintain complete and accurate medical records for residents. This finding was evident for 1 of 26 residents reviewed during survey ( Resident #88).