Montcare at Wheaton

In the surveyor’s words

From the most serious findings on record at Montcare at Wheaton, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 11, 2024

  Based on observations and interviews with facility staff, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include: 1) During an initial tour on 6/17/24 at 8:52 AM of the facility's walk-in refrigerator with staff #32, corporate food services manager, the following observations were made: - an opened thickened lemon-flavored water with an open date of 6/10/24 and a use-by date of 6/17/24. Staff #32 stated that once opened, the thickened water must be used in 5 days. […]

• No harm, potential for more than minimal, patternF755Jan 9, 2026

  Number of residents sampled: Number of residents cited: Based on observations and interviews it was determined that the facility staff failed to return medications to the pharmacy when residents were discharged or when the physician ordered a dose change, and the pharmacy failed to specify how much fluid to add to a powdered medication. This deficient practice was evidenced in 4 (#2, #100, #101, #103) residents who were discharged and 1 (#59) resident whose medication dose was adjusted and 2 (#24, #35) residents whose medication order was incomplete. The deficient practice was discovered during the recertification survey. The findings include:On 01/08/26 at 9:05 am the surveyor observed Licensed Practical Nurse #26 prepare Resident #35 medications. […]

• No harm, potential for more than minimal, patternF761Jan 9, 2026

  Number of residents sampled: Number of residents cited: Based on observations and interview it as determined that the facility staff failed to store and label medications in accordance to professional principles as evidenced of loose medications on the medication cart. This deficient practice was evidenced in 1 of 1 medication cart inspected during the recertification survey.The findings include:On 01/09/26 at 10:53 am when the surveyor inspected the medication cart assigned to Licensed Practical Nurse (LPN) #26 the surveyor observed nine loose medications in the top drawer, four loose medications in the second drawer, and three loose medications in the third drawer. […]

• No harm, potential for more than minimal, patternF610Jul 11, 2024

  Based on medical record review, pertinent documenatation and staff interviews, it was determined that the facility failed to complete a thorough investigation of an allegation of abuse potential abuse. This was evident for #4 (#137, #104, #107, #108) of 12 residents reviewed for abuse. The findings include Review of Resident #137's medical record on 6/22/24 revealed that the resident had a brief admission to the facility in January 2022. 1) Review of MD00182200, a facility self report of an abuse allegation, revealed that the resident's family had submitted a concern form alleging rough handling by staff while at the facility. […]

• No harm, potential for more than minimal, patternF641Jul 11, 2024

  Based on interviews and medical record review, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#24) of 4 residents reviewed for position and mobility, 1 (#37) of 3 residents reviewed for vision/hearing, 1 (#84) of 4 residents reviewed for hospitalization , and 2 (#35, #67) of 4 residents reviewed for pressure injuries. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. […]