Shea Post Acute Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, policy review and interviews, the facility failed to ensure two residents (#71 and #51) were free from abuse from other residents ( #263 AND #261). The deficient practice could result in residents suffering from psychosocial harm. Findings include: Regarding Resident #51 and #261: - Regarding Resident #51: Resident #51 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, anxiety disorder, cognitive functions, traumatic brain injury and bipolar disorder. A review of the residents current MDS (Minimum Data Set) dated August 29, 2024, revealed a BIMS (Brief Interview of Mental Status) score of 00, which indicates severe cognitive impairment. - Regarding Resident #261: Resident #261 was admitted to the facility on [DATE] with a diagnosis of atrial fibrillation and major depressive disorder. A review of the residents current MDS, dated [DATE], revealed a BIMS score of 14, which indicates no cognitive impairment. A facility reported incident…

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 review of records, staff interviews and review of policies and procedures, the facility failed to ensure that medications were administered per physician ordered parameters for one resident (#194); and failed to ensure medications were not left at the bedside for one resident (#83). The facility census was 94, and the sample was 19 residents. The deficient practice has the potential for residents not receiving medications as ordered by the physician. Findings include: -Resident #194 was admitted on [DATE] with diagnoses of right arm humerus fracture, muscle weakness, hemiplegia and hemiparesis, and protein-calorie malnutrition. The care plan dated May 24, 2023 included the resident was prescribed with an opioid for acute on chronic pain. Interventions included to administer opioid as prescribed. The pain care plan dated May 24, 2023 revealed the resident had acute/chronic pain related to arthritis and right humerus fracture s/p (status post) GLF (ground level fall). Interventions included pain…

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 observations, clinical record review, family and staff interviews, and facility policy and procedure, the facility failed to develop a baseline care plan was developed and implemented related to communication and activity needs for one resident that one resident (#64). The facility census was 94, and the sample size was 19 residents. The deficient practice could result in resident care needs not being met. Findings include: Resident #64 was admitted on [DATE] with diagnoses of fracture of first lumbar, dysphagia, and dementia. The initial admission record dated May 17, 2023 included resident was alert and oriented to place and person, was able to follow simple commands, was able to make self-understood and was able to understand others. Per the documentation, preferred language spoken was Chinese. The activity admission evaluation dated May 17, 2023 revealed the resident does not speak English and the family had to translate majority of questions. Per the documentation, resident will be provided with an…

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 observations, clinical record review, family and staff interviews, and facility policy and procedure, the facility failed to provide care and services related to communication for one resident (#64) assessed with communication/language barriers. The census was 94, and the sample was 19. The deficient practice could result in residents not maintaining their communication abilities. Findings include: Resident #64 was admitted on [DATE] with diagnoses of fracture of first lumbar, dysphagia, and dementia. The initial admission record dated May 17, 2023 included resident was alert and oriented to place and person, was able to follow simple commands, was able to make self-understood and was able to understand others. Per the documentation, preferred language spoken was Chinese. The activity admission evaluation dated May 17, 2023 revealed the resident does not speak English and the family had to translate majority of questions. Per the documentation, resident will be provided with an easy board to translate…

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 observations, clinical record review, staff interviews, and policy and procedure, the facility failed to provide a consistent program of activities that met the interests and supported the well-being for one resident (#64). The census was 94, and the sample was 19. The deficient practice could impact the psychosocial and physical well-being of residents. Findings include: Resident #64 was admitted on [DATE] with diagnoses of fracture of first lumbar, dysphagia, and dementia. The initial admission record dated May 17, 2023 included resident was alert and oriented to place and person, was able to follow simple commands, was able to make self understood and was able to understand others. Per the documentation, preferred language spoken was Chinese. The activity admission evaluation dated May 17, 2023 revealed the resident does not speak English and the family had to translate majority of questions. Per the documentation, resident will be provided with an easy board to translate something she may need or…

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 observations, review of the clinical record, staff interviews and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered to three residents (#88, #194, #83). The medication error rate was 8.11%. The deficient practice could result in further medication errors. Findings include: -Resident #88 Resident #88 was admitted on [DATE] with diagnoses of left patella fracture, right clavicle fracture, anxiety disorder, gastro-esophageal reflux disease, and adjustment disorder with anxiety and depressed mood. A physician order dated May 11, 2023 included for calcium Carbonate-Vitamin D (supplement) tablet 500-200 mg/unit (milligram-unit) Give 1 tablet by mouth one time a day for supplement. During the medication administration observation conducted with a registered nurse (RN/staff #73) on May 31, 2023 at 8:24 a.m., the RN removed a bottle of vitamins from the resident's side table drawer, removed one tablet and placed it in a…

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 clinical record review and staff interviews, the facility failed to ensure the clinical record related to advance directives accurately reflect the wishes for one resident (#53). The deficient practice could result in resident wishes not respected and followed. Findings include: Resident #53 was admitted on [DATE], with diagnoses of acute respiratory failure with hypercapnia, cognitive communication deficit, acute and chronic respiratory failure with hypoxia, Parkinson's disease, hypoxemia, depression, and paranoid schizophrenia. The advanced directive form signed by resident #53 and dated [DATE] revealed the resident was a full code. An advance directive statement form dated [DATE] revealed that the resident wished to be a DNR; and that, in the event of cardiac or respiratory arrest, the resident does not want any resuscitation measures including but not limited to CPR (cardiopulmonary resuscitation), endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation…

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 clinical record reviews, resident and staff interviews, and policy reviews, the facility failed to ensure care and services provided met professional standards for 4 residents, by failing to ensure one resident (#4) had an order for a pressure relief ankle foot orthosis (PRAFO), the physician was notified as ordered when two residents (#52 and #35) blood sugar levels were over 400, and one resident (#83) had an order for a medication and an order to self-administer the mediation. The sample size was 20. The deficient practice could negatively impact residents' care. Findings include: -Resident #4 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, left foot drop, pain in the left hip and major depressive disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS assessment indicated the resident had a diagnosis of left foot drop. An…

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 staff interviews, review of facility documentation, policy and procedure, and the Centers for Medicare and Medicaid Services (CMS) Interim Final Rule related to Long-Term Care (LTC) Facility Testing Requirements and COVID-19 Health Care Staff Vaccination, the facility failed to ensure three unvaccinated contract staff were tested based on parameters set for COVID-19 testing frequency. The deficient practice can result in COVID positive staff not being identified and the spread of infection to residents and staff. Findings include: Review of facility documentation revealed the facility had approximately 37 contract staff on board. A review of the facility's documentation of staff vaccination status revealed the following contract staff were unvaccinated and had an exemption: -Hospice certified nursing assistant (CNA/staff #112); -Hospice registered nurse/case manager (RNCM/staff #111); and, -X-ray technologist (staff #113). Regarding the X-ray technologist (staff #113) The exemption request signed by staff #113 and dated December 2, 2021 included that staff #113 agreed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity was maintained for one resident (#6). The sample size was 20. The deficient practice could result in residents not being treated with dignity. Findings include: Resident #6 was admitted on [DATE] with diagnoses that included depressive disorder, type 2 diabetes mellitus, and age-related physical disability. The comprehensive care plan dated March 18, 2022, revealed the resident has activity of daily living (ADL) deficit related to recent hospitalization. The care plan interventions included promoting dignity and privacy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 which indicated the resident is cognitively intact. The MDS assessment stated the resident needed extensive assistance with bed mobility, dressing and personal hygiene. During an observation conducted on April 11, 2022 at…

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 observation, clinical record review, resident and staff interviews, and policy reviews, the facility failed to ensure one resident (#83) was assessed for self-administration of a medication. The sample size was 20. The deficient practice could result in residents unsafely administering medications. Findings include: Resident #83 was admitted to the facility on [DATE] with diagnoses that included displaced bimalleolar fracture of right lower leg, type 2 diabetes mellitus without complications, muscle weakness and major depressive disorder. The initial admission record dated March 23, 2022 revealed the self-administration of drugs was marked 'No' which indicated the resident did not desire to self-administer drugs. The skin evaluation note dated March 24, 2022 stated that resident #83 had a mid-upper back red, raised rash, provider was made aware and Triamcinolone cream was applied per physician order. A physician order dated March 24, 2022 included Triamcinolone Acetonide Cream 0.1%, apply to the back…

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.