Montowese Center for Health & Rehabilitation

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for medication administration, the facility failed to ensure the charge nurse notified the supervisor when a medication was not available for administration.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for changes made in their medication regimen, the facility failed to review, reconcile, and transcribe physician orders when the resident returned from a consulting physician's appointment.

Inspectors wroteBased on review of clinical records, interviews, and review of facility documentation and policies for one (1) of three (3) residents (Resident #1) reviewed for a change of condition, the facility failed to ensure the resident was evaluated upon return from a hospitalization.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from sexual abuse.

Inspectors wroteBased on clinical record reviews, reviews of facility documentation and facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) who was an active smoker, the facility failed to develop a baseline care plan within forty-eight (48) hours after admission to address the facility smoking policy.

Inspectors wrote16. Resident #2 was admitted to the facility in March 2022 with diagnoses that included quadriplegia, aphasia, and weakness. The physician's orders dated 5/12/24 directed to administer Lovenox (an anticoagulant) injection 40 mg subcutaneously daily to prevent deep vein thrombosis. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, was frequently incontinent of bowel, required a urinary catheter for bladder, and was dependent on staff to assist with eating, dressing, and transfers. The care plan dated 8/21/24 identified Resident #2 had a urinary catheter. Interventions included to monitor for blood and sediment. The care plan also identified Resident #2 required medication that increases the time it takes for the blood to clot. Interventions included to monitor for signs of bleeding in the urine, bowel movements, and bruising. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 20 of 20 residents (Residents #3, 10, 13, 24, 32, 39, 45, 49, 52, 56, 59, 67, 69, 70, 80, 103, 104, 105, 106, and 193), the facility failed to ensure medication administration was completed and documented, per the physician's order on 6/3/24 after the charge nurse left the facility and did not report off, and for 1 of 2 residents (Resident #2) reviewed for urinary catheters, the facility failed to ensure an RN assessment was completed following a change in condition, and for 1 of 3 residents (Resident #50) reviewed for falls, the facility failed to ensure that neurological checks were completed following an unwitnessed fall, and for 1 of 2 residents (Resident #9) reviewed for infection, the facility failed to ensure an RN assessment was completed after the resident had a change in [...]

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #11) reviewed for limited range of motion, the facility failed to ensure splints to treat contractures were applied as per the OT recommendations and physician's orders.

Inspectors wroteBased on review of the clinical record, facility documentation, and interviews for 2 of 5 residents (Resident #9 and 30) reviewed for unnecessary medications, the facility failed to ensure the physician or APRN signed and dated orders and wrote signed and dated progress notes.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #9) reviewed for unnecessary medications, the facility failed to ensure pharmacy recommendations were responded to by the physician and/or APRN.

Inspectors wroteBased on observations, clinical record review, facility documentation, facility policy, and interviews, the facility failed to ensure that nursing staff maintained proper infection control techniques and appropriate hand hygiene procedures for residents who required transmission based and enhanced barrier precautions; and for one sampled resident reviewed for immunizations (Resident #2), the facility failed to ensure that a resident's immunity status was obtained following an identified infection control issue; [...]

Inspectors wroteBased on review of facility documentation, facility policy and interview, the facility failed to designate an individual with the required training and certification to oversee the Infection Control Program.

Inspectors wroteBased on observation and interviews, the facility failed to ensure the 2-way call bell system was functioning.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #43) reviewed for care planning, the facility failed to ensure resident care conferences were completed quarterly, that the resident was invited and attended, and the resident care plan was updated quarterly.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #50) reviewed for falls, the facility failed to ensure interventions were in place after a fall with major injury, and failed to ensure that 1:1 supervision was provided during meal time per the physician's order.

Inspectors wroteBased on clinical record review, facility documentation, and staff interview for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the residents rights were honored by limiting Leave of Absence (LOA) due to contraband.

Inspectors wroteBased on record review, facility documentation, and staff interview for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred in accordance with physician orders.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of four (4) residents reviewed for resident-to-resident altercations, (Resident #2), the facility failed to implement interventions to protect a resident from physical abuse by another resident.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to assure the medical record was complete and accurate to include an RN assessment after a change in condition.

Inspectors wroteBased on review of the clinical records, review of facility documentation, review of policy and procedures and interview with facility staff for 11 of 12 residents reviewed for medication administration omissions or delays in administration (Resident #'s 3, 44, 45, 46, 47, 48, 49, 50, 52, 53 and #40) which had the potential for neglect, the facility failed to complete required reporting documentation, investigate why such omissions or delays occurred and take any corrective action, and failed to report to the state survey agency in accordance with the policy and procedures.

Inspectors wroteBased on review of the clinical records, review of facility documentation, review of policy and procedures and interviews with facility staff for 8 of 12 residents (Resident #'s 24, 25, 45, 46, 50, 52, 53, and 40) reviewed for medication administration which resulted in medication errors, the facility failed to administer medications in accordance with physician/advanced practice registered nurse orders to ensure residents were free from significant errors.

Inspectors wroteBased on review of clinical records, review of facility documentation, and interviews with facility staff for 7 of 7 residents self-administering medication (Resident #'s 54, 55, 56, 57, 58, 59, and 60), the facility failed to conduct a medication self-administration assessment in accordance with facility policy.

Inspectors wroteBased on observations and interview the faciity failed to ensure recent survey activites were accessbile to residents and the public.

Inspectors wroteBased on clinical record review and interview for 2 of 2 residents (R# 5 and Resident #13) that had an increase in weight or had a change of condition, the facility failed to notify the physican of a weight gain or the responsbile person of the change in condition.

Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy and procedures and interviews with facility staff, for two of two residents reviewed for discharge planning (Resident #21 and #26 ) the facility failed to provide a safe and comprehensive discharge plan that included education to caregivers regarding the discharged resident's level of support that would be needed and provided upon discharge from the facility or provide the resident with the appropriate medication.

Inspectors wroteBased on clinical record review and interview for 1 resident (R#10) reviewed as a new admission to the facility, the facility failed to have the orders signed timely.

Inspectors wroteBased on review of the clinical record, review of the policy and procedure, and interview with facility staff for one resident reviewed for falls (Resident #6), the facility failed to ensure the fall risk assessment was done at admission in accordance with the policy and procedures.

Inspectors wroteBased on review of the clinical record, review of facility policy and procedures and interview with facility staff for 2 of 4 residents (Resident #19 and 36) reviewed for non-pressure skin conditions, the facility failed to follow physician orders, failed to document weekly skin assessments for the right 2nd toe and left 4th toe and failed to ensure assistance was provided to ensure the resident had access to his/her scheduled follow up appointment.

Inspectors wroteBased on review of the clinical records, staff interviews, and facility policy for 2 of 4 residents (Resident #19 and #28) reviewed for skin conditions related to pressure, the facility failed to follow physician orders, failed to document weekly skin assessments for a pressure ulcer noted on the coccyx and failed to follow the policy on the prevention and management of pressure ulcers.

Inspectors wroteBased on review of the clinical records, staff interviews, and review of facility policyand procvedures for 7 of 7 sampled residents (Resident # 1. 5, 9, 18, 23, 29, and 42) reviewed for nutrition and hydration, the facility failed to monitor weights or monitor intake and output in accordance with physician orders.

Inspectors wroteBased on review of the clinical record, review of the facility policy and procedure, and interviews for 1 resident reviewed for pain management (Resident #11) , the facility failed to identify and intervene timely for complaints of pain.

Inspectors wroteBased on review of clinical records for 8 of 8 residents who experienced singficant medication errors (Resident #'s 24, 25, 45, 46, 50, 52, 53, and 40) and review of facility documentation, the facility failed to ensure sufficient staffing on 1/28/23 between 7:00 AM - 11:30 AM to meet the resident's needs.

Inspectors wroteBased on review of 2 of 2 personnel files, the facility failed to complete performance appraisals in accordance with the facility policy.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy and procedures, and staff interviews for one sampled resident (Resident #12) reviewed for hydration, the facility failed to ensure a laboratory test was obtained iin accordance with physician orders.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy for 1 sampled resident (Resident #12) reviewed for hydration, the facility failed to ensure Resident #12's laboratory results were available in the resident's medical record.

Inspectors wroteBased on review of the clinical record, review of facility documentation and interview with facility staff for one sampled resident (Resident #18) who had a diagnostic test ordered, the facility failed to obtain the test in accordance with provider orders.

Inspectors wroteBased on review of the clinical record, facility policy and interview for 1 of 1 resident (Resident #24) reviewed for dietary preferences, the facility failed to conduct an initial nutritional assessment in accordance with the policy and procedures and/or to assess and establish menu preferences for the resident reviewed.

Inspectors wroteBased on review of the clinical record, staff interviews, and review of facility policy for 1 of 4 residents (Resident #19) reviewed for wounds, the facility failed to document weekly skin assessments for the coccyx, right 2nd toe and left 4th toe, and failed to provide accurate documentation in the electronic health record.

Inspectors wroteBased on observations and interview with facility staff, the facility failed to ensure a safe environment.

Inspectors wroteBased on review of the clinical record, facility documentation, and facility policy for one (1) of three (3) residents, (Resident # 3), reviewed for abuse, the facility failed to report an allegation of abuse timely to the state agency.

Inspectors wroteBased on review of the clinical record, facility documentation, and facility policy for one (1) of three (3) residents,(Resident # 3), reviewed for Abuse, the facility failed to complete an investigation related to an allegation of abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, and interviews for one (1) of three (3) residents,(Resident # 3), reviewed for Abuse, the facility failed to implement a care plan to address the resident's resistiveness to care.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for a change in condition, the facility failed to neurological checks after an unwitnessed fall in accordance with facility policy.

Inspectors wroteBased on review of facility documentation and interview for two (2) of three (3) employee records reviewed for annual abuse training, the facility failed to ensure certified nursing staff had annual abuse training in accordance to facility policy.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who were reviewed for medication administration, the facility failed to follow their established professional standard when transcribing a physician's order, documenting at the time a medication was administered, and administer the correct dated dose of a medication.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who were reviewed for medication administration, the facility failed to administer a medication in accordance with the new physician's order.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for three (3) of three (3) residents (Resident #1, Resident #2, and Resident #3) who were reviewed for intake and output (I/O), the facility failed to record fluid intake for a resident(s) on I & O, the facility further failed to ensure the testing of the glucometer according to facility policy.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 2 of 3 sampled residents (Resident #4 and Resident #5) who were reviewed for parenteral fluids, the facility failed to ensure Intravenous (IV) fluids were implemented in a timely manner.

Inspectors wroteBased on clinical record reviews, facility documentation and interviews, for three of three sampled residents (Resident #2, #3, and #4) who were reviewed for the administration of the afternoon and evening medications, the facility failed to administer medications at the time ordered and in accordance with the standard of practice, one hour before or after the designated time and for one of three sampled residents (Resident #3) who was reviewed for pressure ulcers, the facility failed to administer a treatment to the coccyx at the time ordered and in accordance with standard of practice and for one sampled resident (Resident #1) who had a central venous access device, the facility failed to change the central venous access device dressing at the time ordered and in accordance with the standard of practice.

Inspectors wroteBased on clinical record reviews, review of facility documentation, review of facility policy, and interviews for two of four sampled residents (Residents #11 and #60) reviewed for hospitalization, the facility failed to ensure the residents were free of significant medication errors related to critical medications not being administered for significant amounts of time which resulted in the residents experiencing a change in condition that required re-hospitalization. The failures resulted in a finding of Immediate Jeopardy.

Inspectors wroteBased on clinical record reviews, review of facility documentation, review of facility policy, and interviews the facility failed to ensure for two of four newly admitted residents (Resident #11 and Resident #60), that hospital discharge medications were accurately reconciled, transcribed and communicated with each resident's facility physician to ensure orders for necessary medications were obtained and administered to provide for each resident's healthcare needs. These facility failures resulted in serious health issues and rehospitalizations for both residents. the facility failed to ensure that medications were administered as ordered by the physician which resulted in the resident's requiring re-hospitalization.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, and interviews for 1 sampled resident (Resident #57) who utilized an indwelling catheter, the facility failed to ensure that the resident was scheduled for a consult with a specialized physician was scheduled.

Inspectors wroteBased on clinical record reviews, review of facility's documentation and interviews for 6 of 11 sampled residents (Residents #24 ,#49, #65, #75, #81 and #300) reviewed for lab services, the facility failed to ensure that laboratory services were available within the facility resulting in the residents being sent out to the hospital to have physician ordered laboratory tests completed.

Inspectors wroteBased on observations, review of facility's policy, and interviews, the facility failed to ensure two dietary staff had face masks in place that completely covered the nose, mouth and chin to prevent the spread of COVID -19 infection, and failed to ensure that four nursing staff had nails that were at a safe and acceptable length to prevent possible injury and the spread of infection.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 sampled residents (Residents #202 & #302) reviewed for advanced directives, the facility failed to ensure that advanced directives were addressed.

Inspectors wroteBased on clinical record review, review facility's documentation , facility policy review and interviews for 1 of 5 sampled residents (Resident #60) reviewed for pain management, the facility failed to ensure that the physician was notified that Levothyroxine was not available and not administered for 3 consecutive days.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled resident (Resident #12) with a history of elopement, the facility failed to ensure one to one monitoring was consistently completed.

Inspectors wroteBased on clinical record review, facility documentation review, and interviews for one of 1 sampled resident (Resident # 45) reviewed for Hospice, the facility failed to develop a comprehensive care plan after a significant change in condition.

Inspectors wroteBased on clinical record review, observation, facility documentation review, facility policy review and interviews for 1 of 3 sampled resident (Resident #23) reviewed for accidents, the facility failed to ensure that the smoking assessment was done in accordance with the facility's policy.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for 1of 2 sampled residents (Resident # 71) reviewed for unnecessary medications, the facility failed to ensure that the recommendations made by the pharmacist after completion of the medication regimen review were addressed timely by the prescriber/physician including timely completion of a baseline AIMS (abnormal involuntary movement scale) assessment.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews, the facility failed to ensure that eye drops were labeled with the date opened and expired IV supplies and solutions were removed and discarded timely.

Inspectors wroteBased on observation, review of facility policy and interviews for 2 employees (NA #1 and NA #2) who did not display an identification badge inclusive of a picture, the facility failed to ensure that the staff members displayed identification badges with their name and picture.

Inspectors wroteBased on observations, review of facility documentation and interviews, the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food safety and for for one of five sampled residents (Resident #39) reviewed for nutrition, the facility failed to ensure a meal was held at an appropriate holding temperature for an appropriate amount of time according to professional standards.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for two of three sampled residents (Resident #39 and #103) reviewed for the environment, the facility failed to provide a homelike, neat and well kept resident room and failed to provide storage to accommodate a resident's need.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one of six sampled residents (Resident #98) reviewed for nutrition, the facility failed to notify the consultant dietitian of a significant weight loss and the Advanced Practice Registered Nurse.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #9) reviewed for an allegation of mistreatment, the facility failed to ensure their grievance policy was followed.

Inspectors wroteBased on clinical record review, review of facility documentation and interviews for one of five sampled residents reviewed for allegation of abuse (Resident #29), the facility failed to protect the resident from verbal abuse by staff.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #39) reviewed for an allegation of mistreatment, the facility failed to report an allegation of mistreatment to the state agency in a timely manner.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for two sampled residents(Resident #39 and Resident # 102) reviewed for Activities of Daily Living (ADL), the facility failed to provide finger nail care for a dependent resident.

Inspectors wroteBased on clinical record, facility documentation review and interview for one of two residents in survey sample reviewed for pressure ulcers (Resident#27 ), the facility failed to identify and implement new interventions to prevent the development of a pressure ulcer.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for one sample resident (Resident #16) reviewed for Podiatry services, the facility failed to ensure the resident was seen by podiatry in a timely manner.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one of two sampled residents for (Resident # 4) reviewed for accidents, the facility failed to ensure an assessment was conducted after a fall and (Resident #16) reviewed for accidents, the facility failed to ensure Resident #16 was supervised during a shower.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy and interviews for one of six sampled residents (Resident #98) reviewed for nutrition, the facility failed to ensure a re-weight following a significant weight loss, failed to appropriately monitor a resident for intake and output according to a physician's order and failed to ensure appropriate meal provision for a resident with an appointment.

Inspectors wroteBased on clinical record review, review of facility documentation and interviews for one sampled resident (Resident #311) requiring Central Venous Access Device (CVAD) and receiving total parenteral nutrition (TPN), the facility failed to ensure CVAD was consistently flushed per physician's orders and to follow facility policy to prevent possible clogging.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #16) reviewed for dental services, the facility failed to ensure Resident #16 was seen by dental in a timely.

Inspectors wroteBased on observation of the kitchen, facility documentation, facility policy, and interviews, the facility failed to ensure garbage containers had lids or covers so waste was properly contained.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy, and interviews for (Resident # 10) the facility failed to dispose of linen to prevent the transmission of infection and one sample resident (Resident # 56) reviewed for Infection Control, the facility failed to follow infection practices by identifying a resident who was on contact precautions for a Multi Drug Resistant Organism and for (Resident # 103), the facility failed to store personal items to prevent the transmission of infection