Inspection·June 16, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide R2 with the correct medication at discharge. This failure resulted in R2 being discharged with another resident's medication, ingesting the incorrect medication, resulting in urinary retention and hospitalization for urinary catheterization. This affected one(R2) of three residents reviewed for discharge. Residents Affected - Few Findings Include: Facility Final Investigation Report (dated 06/01/2023) regarding R2 documents in part: R2 was admitted to facility on April 27, 2023, for short-term rehabilitation, and was discharged on May 18,2023. He was alert and oriented x4. R2 had teaching completed upon discharge by agency nurse, patient verbalized understanding. We were notified by physician on June 01,2023 of a medication error with R2 after discharge from our SNF unit. Doctor had some communication with R2's primary care physician at hospital. Information was passed on that R2 received his medication upon discharge, but also two medication cards for another patient. The other medications were Oxybutynin 5mg and Atorvastatin 20mg. R2 took one dose of 5mg Oxybutynin the evening of May 18th. This medication error triggered urinary retention with R2, and he had to be catheterized in the hospital. R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Cerebral infarction, unspecified, Hemiplegia and Hemiparesis following unspecified Cerebrovascular disease affecting left dominant side, Essential (Primary) Hypertension, Unspecified lack of expected normal physiological development in childhood, Cerebral Infarction due to unspecified occlusion or stenosis of right middle cerebral artery, Muscle Weakness (Generalized). On 06/14/2023 at 10:32am V3 (Director of Nursing/DON) stated, When R2 discharged from the facility on 05/18/2023, it was an agency nurse who did the discharge education with R2. V4 (agency nurse) is the one who did the medication teaching upon R2's discharge. V4 is the one who packed R2's medications and sent it home with R2 on the day of discharge. From my understanding, R2 was sent home with 2 wrong medications, and was taking the wrong medication at home. R2 was sent home with medication for urinary retention, and R2 did not have anything wrong with his bladder. We had no knowledge that R2 went home with the wrong medication. The facility had no knowledge that this medication error transpired upon discharge from the facility. The facility was notified by R2's physician of this medication error 2 to 3 weeks after R2's discharge from the facility. R2 was sent home with Oxybutynin and Atorvastatin by error. Oxybutynin is for an overactive bladder, and if taken when not needed, can cause urinary retention. The medication, Oxybutynin, causes the bladder to relax, and when taken by error, it can cause urinary retention. When a resident is discharged from the facility, the nurse does the medication reconciliation with the doctor prior to discharge. Then the nurse goes over the medication with the resident, and the nurse sends the resident's medication home with the resident. R2 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145748 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)