Montowese Center for Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Montowese Center for Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Aug 16, 2022

  Based 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. The findings include: 1. […]

• Actual harm, isolatedF600Jan 15, 2025

  Based 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. The findings include: 1. Resident #1 was admitted with diagnoses including malignant neoplasm of the brain, epilepsy with seizures, cognitive communication deficit and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of two (2) indicative of severely impaired cognition and was dependent on staff for bed mobility and transfers. […]

• Actual harm, isolatedF760Jun 7, 2023

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2)residents reviewed for medication administration,(Resident #2) the facility failed to administer medication in accordance with facility policy resulting in a significant medication error with subsequent hospitalization . The findings include: Resident #2 was admitted to the facility with diagnoses that included Congestive Heart Failure, Diabetes Mellitus Type II, hypothyroidism, hypertension, Atrial Fibrillation and dementia. […]

• Actual harm, isolatedF684Aug 16, 2022

  Based 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 rehospitalization s 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 . The findings include: 1. […]

• Actual harm, isolatedF684Jun 22, 2022

  Based on review of the clinical record, facility documentation, facility policy and interviews for one of three residents (Resident #1) who were reviewed for laboratory services, the facility failed to report critical laboratory values in a timely manner, and for one of three residents (Resident #1) reviewed for medication administration, the facility failed to administer medications according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1 's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission nursing assessment dated [DATE] identified Resident #1 was cognitively intact and required the assistance of one staff with Activities of Daily Living (ADL's) and was independent with eating. […]