Promenade Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, facility document review, and facility policy and procedure review, the facility failed to ensure residents were free from physical restraints, for 1 (Resident #82) of 2 residents reviewed. Based on facility document review, interviews and facility policy review, the facility failed to ensure residents were free from physical restraints, for one (Resident #82) of two residents reviewed. The findings include: Review of the Facility's Incident Report involving Resident #82 on 12/15/2025, indicated that on 04/16/2025 during the evening shift, no time specified, per Certified Nursing Assistant (CNA) #2's witness statement, upon entrance into Resident #82's room CNA #3 and CNA #4 were tying a sheet around resident's waist and to the back of the chair. Licensed Practical Nurse (LPN) #5 was also in the room with the resident at the time the incident occurred. CNA #2 reported the incident to Lead Certified Nursing Assistant (LCNA) #1 on 04/17/2025 at 6:00 PM. LCNA #1 immediately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number of residents sampled: Number of residents cited: Based on record review, observation, interview and facility policy review, the facility failed to ensure a mechanical lift was in safe operational condition prior to the lift and transfer of one (Resident #34) of one resident reviewed for mechanical lifts and transfers. The findings include: Review of Medical Diagnosis for Resident #34 indicated the resident had diagnoses which included hemiplegia [paralysis of one side of the body], kidney failure, and atrial fibrillation [irregular heart rhythm]. Review of a quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of11/06/2025 revealed, a Brief Interview of Mental Status [BIMS] score of 10, which indicated moderate cognitive impairment. The MDS also indicated Resident #34 was dependent on staff for toileting, personal hygiene, bathing and lower body dressing. Maximum assistance was required for dressing the upper body. Review of a Care Plan for Resident #34 revised 06/23/2022, indicated a self-care deficit related to limited mobility, paralysis on one side of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review observation, interview and facility policy review, the facility failed to ensure proper hand hygiene was maintained during perineal care for one (Resident #34) of one resident reviewed.The findings include:Review of Medical Diagnosis revealed, Resident #34 had diagnoses which included hemiplegia [paralysis of one side of the body], kidney failure, and atrial fibrillation [irregular heartbeat.] Review of a quarterly Minimum Data Set [MDS] with an Assessment Reference Date of 11/06/2025, revealed a Brief Interview of Mental Status score of 10, which indicated moderate cognitive impairment. The MDS also indicated Resident #34 was dependent on staff for toileting, personal hygiene, bathing, and lower body dressing.Review of a Care Plan for Resident #34 revealed a self-care deficit related to limited mobility, hemiplegia, and balance impairment (revised 06/23/2022), and that Resident #34 required two staff assistance for incontinent care. Review of a Perineal Care Competency for Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the facility failed to ensure opened food was dated for food service safety in 1 of 1 kitchen. The failed practice had the potential to affect all 85 residents. Specifically, the facility failed to date an opened bag of salad mix. The findings are: On 07/22/2024 at 11:00 AM, the surveyor observed an 18 ounce bag of salad mix opened in the refrigerator with no date on it. The Dietary Manager took the bag and placed it in a box of other salad mixes. On 07/23/2024 at 10:05 AM, the District Dietary Manager and this surveyor observed the same bag of salad mix without a date on the bag. At 10:10 AM, the Dietary Manager pulled out the salad bag and showed the top of bag and reported that he had placed the date there the day before, but no visible date was observed. The Dietary Manager removed the bag at that time to place a date on the bag. On 07/24/2024 at 10:35 AM, an interview with the Dietary Manager revealed that all items should be dated upon opening, and all employees are responsible for dating food when opening food. The Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews, the facility failed to ensure a resident was free from the use of an unnecessary restraint for 1 (Resident #23) of 1 sampled resident reviewed for the use of restraints. Specifically, Resident #23 had a seat belt attached to a wheelchair and fastened around resident's waist preventing resident from standing. Findings include: A review of a facility policy titled, Use of Restraints, with a revised date 03/01/2022, indicated, Policy Statement Restraints shall only be used for the safety and well-being of the resident . shall only be used to treat the resident's medical symptom(s) and never for .the prevention of falls .2 .resident cannot remove a device in the same manner in which the staff applied it . and this restricts his/her typical ability to change position or place, that device is considered a restraint .4. Practices .prevent resident mobility are considered restraints .c. Placing a resident in a chair that prevents the resident from rising .6. Prior to placing a resident in restraints .pre-screening assessment and review to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene when providing resident meal trays to the residents who eat in their room and receive meals from the dining room on the 100 Hall; failed to ensure hand hygiene was performed between residents, and failed to ensure staff did not touch medication with bare contaminated hands for 1 (Resident #31) of 2 sampled residents observed during medication pass to prevent the potential spread of infections. Findings include: A review of a facility policy titled, Handwashing/Hand Hygiene, dated 07/17/2012, indicated, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents .7. Use an alcohol-based hand rub .soap . and water for the following situations .p. Before and after assisting a resident with meals . A review of a facility Course Completion History…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure food items stored in the refrigerator and freezer were covered or sealed and expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 97 residents who received meals from the kitchen (total census: 97), as documented on a list provided by the Dietary Supervisor on 05/16/23. The findings are: 1. On 05/16/23 at 9:22 AM, an opened box of bacon was on a shelf in the walk-in refrigerator. The box was not covered or sealed. 2. On 05/16/23 at 9:25 AM, the following observations were made in the freezer: a. An opened box of omelets was on a shelf in the freezer. The box was not covered or sealed. b. 2 opened boxes of cookies were on a shelf in the freezer. The boxes were not covered or sealed. 3. On 05/16/23 at 9:50 AM, the area above the ice machine panel had an accumulation of pink/grayish slimy residue on it. The Surveyor asked the Dietary Supervisor to wipe the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1meals observed. This failed practice had the potential to affect 68 residents who received regular diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 05/16/23. The findings are: 1. The menu for the lunch meal documented residents on regular diets were to receive 3 ounces of honey glazed ham. 2. On 05/16/23 at12:20 PM, residents on regular diets were served a small piece of ham. 3. On 05/16/23 at 1:14 PM, Dietary Employee #1 was asked to weigh the same amount of ham served to the residents. She did and stated, It weighed 1.5 ounces.

Based on observation, record review, and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 19 residents on the 100 Hall, 18 residents on the 200 Hall, 16 residents on the 300 Hall, and 16 residents on the 400 Hall who received meal trays in their room as documented on a list provided by Dietary Supervisor on 05/16/23 at 2:10 PM. The findings are: 1. On 05/16/23 at 12:34 PM, an unheated cart that contained 18 trays for lunch was delivered to the 200 Hall by Certified Nursing Assistant (CNA) #1. At 12:49 PM, immediately after the last resident received their tray in their room on 200 Hall, the temperatures of the food items on a test tray were checked and read by the Dietary Supervisor with the following results: a. Milk - 47.5 degrees Fahrenheit. b. Ground meat with gravy - 107 degrees Fahrenheit. c. A carton of ice cream…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.