Montgomery Children's Specialty Center

In the surveyor’s words

From the most serious findings on record at Montgomery Children's Specialty Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Aug 20, 2021

  Based on interviews and review of the job description for the Director of Nursing Services and the Administrator, the Administrator and Director of Nursing (DON) failed to ensure systems were in place to assure all required COVID-19 staff testing was performed as required based on county positivity rate. Further, neither the Administrator or Director of Nursing, the only two staff with access to COVID-19 lab reports, followed up on testing results to ensure positive results were reviewed and acted upon as needed in a timely manner. As a result of this systematic failure, the facility failed to identify and act upon a contracted housekeeper (HSK #1)'s positive routine COVID-19 test result. On 8/6/2021, a contracted housekeeper (HSK #1) COVID-19 specimen was collected. […]

• Immediate jeopardy, widespreadF886Aug 20, 2021

  Based on interviews, review of the Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey & Certification Group Ref: QSO-20-38-NH, the facility's policy titled COVID-19 Testing Guidance, other facility documents and a complaint received, the facility failed to timely identify and act upon an unvaccinated, asymptomatic contracted housekeeper's positive COVID-19 test result. On 8/6/2021, a contracted housekeeper (HSK #1) COVID-19 specimen was collected. The positive result was finalized and available to facility staff on 8/7/2021 at 2:14 PM; however, the facility did not implement a system to review this information to ensure the positive result were acted upon until the following Tuesday, 8/10/2021. […]

• No harm, potential for more than minimal, widespreadF814May 25, 2023

  Based on observation, interview, the facility's policy for Dispose of Garbage and Refuse, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to ensure the side door of the dumpster was closed on 5/22/2023 at 6:45 PM to prevent the potential for rodents being attracted to and possibly entering the facility. This had the potential to affect 45 of 45 residents in the facility. Findings include: The facility's policy for Dispose of Garbage and Refuse, dated August 2017, included the following: Policy Statement All garbage and refuse will be collected and disposed of in a safe and efficient manner. The U.S. FDA 2022 Food Code included the following: . 5-5 Refuse, Recyclables, and Returnables . 5-501.13 Receptacles. (A) . […]

• No harm, potential for more than minimal, patternF803May 25, 2023

  Based on observation, interview, review of the facility's policy for Menus, the facility's menu and diet guides for Week 1, Tuesday (Day 3) for Lunch on 5/23/2023, the residents' Diet Cards (sub-heading: Category Information) for Lunch on 5/23/2023, and the residents' Tray Tickets for Lunch on 5/23/2023; the facility failed to ensure food was portioned as specified by the approved menu for lunch on 5/23/2023. The facility also failed to ensure nutritional adequacy and appropriate modification of texture by not consulting with the Registered Dietitian before making substitutions to the menu for lunch on 5/23/2023. […]

• No harm, potential for more than minimal, patternF812May 25, 2023

  Based on observation, interview, the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility's policies for Food: Preparation and Equipment, and the facility's inservice information for Time and Temperature Control and Recording Inservice; the facility failed to prevent possible cross-contamination from a soiled manual can opener and a food preparation sink drain without an air gap on 5/23/2023. The facility further failed to ensure the food thermometer was properly checked and calibrated to check food temperatures accurately on 5/23/2023. […]