Boca Circle Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow their posted scheduled mealtime for tray deliveries on 2 out of 2 observations. The findings included: 1. In an observation conducted on 02/03/2025 between 12:00 PM and 2:00 PM this surveyor observed discrepancies between the stipulated lunch tray's arrival time and the actual arrival time. The lunch trays stipulated arrival time were as follow: Main Dining Room: 12:00 PM, Assisted Dining Room: 12:10 PM, 100 Hall: 11:30 AM, 200 Hall: 11:40 AM, 300 Hall: 11:50 AM. The lunch trays actual arrival time were as follow: Main Dining Room: 12:52 PM, Assisted Dining Room: 1:10 PM, 100 Hall: 1:15 PM, 200 Hall: 1:43 PM, 300 Hall: 1:38 PM. 2. In an observation conducted on 02/04/2025 between 11:30 PM and 12:30 PM this surveyor observed discrepancies between the stipulated lunch tray's arrival time and the actual arrival time. the lunch trays stipulated arrival time were as follow: Main Dining Room: 12:00 PM, 500 Hall: 11:50 AM, 600 Hall:…

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, interviews and record review, the facility failed to ensure disposal of garbage and refuse in a sanitary manner. The findings included: A review of the facility's policy titled, Dispose of Garbage and Refuse, dated 8/2017, showed the following: all garbage and refuse will be collected and disposed of in a safe and efficient manner. The Dining Service Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. In an observation conducted on 02/03/25 at 8:42 AM, in the outside area, a large blue metal construction dumpster was noted. The opened dumpster showed garbage bags and multiple food boxes inside the dumpster. Closer observation revealed a foul smell and insects flying around the construction dumpster. In this observation, the facility's maintenance director stated that he has told the kitchen staff multiple times that this construction dumpster is only used for construction garbage and not to throw any other garbage that is coming from 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to properly follow hand hygiene protocol during respiratory treatments and failed to handle medications in a sanitary manner while dispensing medications for 2 of 5 sampled residents reviewed for medication administration (Resident #90 and #79). In addition, the facility failed to follow sanitary procedures for disconnecting dialysis treatment for 1 of 1 sampled resident reviewed for dialysis (Resident #101). The findings included: Review of the facility's policy titled, Administering Medications, revision date 02/21/23, included the following: To ensure that medications are administered in a safe and timely manner, and as prescribed. General Guidelines: 3.Medications are administered in accordance with prescriber orders, and current standards of practice. a. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications,…

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, interviews and record review, the facility failed to maintain laundry equipment in a clean manner, store linens, and dispose of Personal Protective Equipment (PPE) in a manner to ensure infection control; and the facility failed to provide appropriate infection control surveillance related to scabies outbreak; the facility failed to practice hand hygiene during catheter care observation for 1 sampled resident for catheter care (Resident #67); the facility failed to maintain a sterile environment during trach care for 1 resident sampled for respiratory care (Resident #401). The findings included: 1.) Review of the facility's policy titled, Surveillance -Infections with an effective date of 04/01/22 that included: The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infection (HAI), to guide appropriate interventions and to prevent future infections. Under Section General Guidelines…

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, interviews and record review, the facility failed to provide eating assistance in a dignified manner for 4 of 4 sampled residents observed for in-room dining, Residents #3, #9, #25 and #53. The findings included: Review of the facility's policy titled Activities of Daily Living effective date 04/01/22 documents a resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition . 1) Review of Resident #3's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included Dysphagia (difficulty swallowing) Heart Disease, Severe Protein-Calorie Malnutrition, Muscle Wasting and Depression. Review of Resident #3's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 10 indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive…

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, interviews and record review, the facility failed to provide fingernails grooming for 2 of 2 sampled residents, Residents #9 and #53, observed for nail grooming. The findings included: Review of the facility's policy titled Activities of Daily Living effective date 04/01/22 documents a resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good .grooming . 1) Review of Resident #9's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included Pyogenic Arthritis, Macular Degeneration, Muscle Wasting and Atrophy, and Major Depressive Disorder. Review of Resident #9's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance to total assistance from the staff to complete…

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, interviews, and record reviews, the facility failed to follow Physicians ' orders for tube feeding for 1 of 2 residents reviewed for tube feeding, Resident #64. The findings included: Record review revealed that Resident #64 was admitted on [DATE] with diagnoses of Hypertension, Dysphagia, and Diabetes. The order summary report revealed an order for Glucerna 1.5 (tube feeding formula), infuse at 50 milliliters (ml) an hour over 20 hours from 4:00 PM to 12:00 PM, which was dated 10/06/23. In an observation conducted on 10/16/23 at 10:30 AM, Resident #64 was noted in bed with the tube feeding Glucerna 1.5 running at 50 ml an hour. Closer observation showed a tube feeding bottle at the 100 ml mark out of a 1000 ml capacity bottle. The date on the tube feeding bottle showed that it was started on 10/14/23, with no start time. In an observation conducted on 10/16/23 at 5:10 PM, Resident #64 was noted in her room with the tube feeding Glucerna 1.5 at 50 ml an hour, which started at 4:20 PM and…

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, interviews, and record review, the facility failed to ensure that a resident receiving dialysis was consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident ' s goals and preferences for 1 of 1 resident reviewed for dialysis (Resident #43). The findings included: According to the State Operations Manual section §483.25(l), Dialysis, the communication process should include how the communication will occur, who is responsible for communicating, and where the communication and responses will be documented in the medical record, including but not limited to Nutritional/fluid management including documentation of weights, Resident compliance with food/fluid restrictions or the provision of meals before, during and after dialysis and monitoring intake and output measurements as ordered. Resident #43 was admitted to the facility on [DATE] with End Stage Renal Disease and Dependence on Renal Dialysis diagnoses. The order noted for a Renal…

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, interviews and record review, the facility failed to ensure controlled medication were removed from the controlled box after the medication was discontinued for 2 of 6 sampled residents (Resident #33 and #74), and failed to obtain a physician order for a controlled medication removed from the controlled box for 1 of 6 sampled residents (Resident #33) reviewed during the controlled drugs record review at the facility's progressive units. The findings included: 1) Review of Resident #33's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Intervertebral Disc Degeneration, Lumbar Region, Senile Degeneration of Brain and Depressive Disorders. Review of Resident #33's active physician orders lack a written order for Oxycontin ( a controlled drug) ER 10 milligrams (mg) every morning for non-acute pain. Further review revealed Oxycontin drug was discontinued on 04/25/23. On 10/19/23 at 2:01 PM, a side by side review of Resident #33's Controlled…

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 interviews and record review, the facility failed to monitor behaviors as per pharmacy recommendations for 3 of 5 residents reviewed for unnecessary medications (Residents #53, Resident #43, and Resident #8). The findings included: Review of the facility's policy titled Psychotropic Drug Use (no date) showed the following: The interdisciplinary team helps identify the behavioral target symptoms and specific behavioral concerns that warrant using an antipsychotic drug in the care plan intervention. 1. The customer's behavior is monitored. 2. The specific behavioral problems are tracked and documented as to the number of episodes or hours (if- for pacing, yelling, or screaming) as determined by the interdisciplinary team care plan. 1. Resident #53 was admitted to the facility on [DATE] with diagnoses of Dementia, Kidney Disease and Behavioral Disturbances. The Quarterly Minimum Data Set, dated [DATE] showed a Brief Interview of Mental Status (BIMS) that the resident is severely cognitively impaired. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the medication error rate was 7.69 percent. Two (2) medication errors were identified while observing a total of 26 opportunities, affecting Resident #36. The findings included: Review of the facility's policy titled Administering Medications/ revised on 02/21/23 documented .medications are administered in accordance with prescriber orders, and current standards of practice .if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident .the person preparing or administering the medication should contact the prescriber, the Attending Physician or the facility's Medical Director to discuss the concerns . Review of Resident #36's clinical record documented an admission on [DATE] and readmission on [DATE]. The resident diagnoses included Hypertension, Adult Failure to Thrive, Dementia, and Depressive Disorders. Review of Resident #36's Minimum…

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 observations, interviews, record reviews, and policy review, the facility failed to dispose of expired medications in 1 of 4 medications carts and in 2 of 2 medication storage rooms. The findings included: Review of the facility's policy titled Medication Storage, revealed the following: Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida Department of Health guidelines. Procedure: Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. 1. A medication storage room observation in the facility's Subacute area was conducted on 10/19/23 at 1:30 PM with Staff O, Licensed Practical Nurse (LPN). While inspecting the medication room refrigerator, an observation was made of two small intravenous (IV) Sodium Chloride bags which had an expiration date of 10/15/23 (Photographic evidence obtained). Further observation revealed expired medical supplies including a clear/zipper…

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, interviews, and record review, the facility failed to provide adaptive devices during dining as ordered by physician for 1 of 1 sampled residents for adaptive devices (Resident #49). The findings included: Review of the facility's policy titled, Assistive Devices with a revised date of 09/2017 included: Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's ability to eat or drink independently. Record review for Resident #49 revealed the resident was originally admitted to facility on 08/30/23 with most recent readmission on [DATE]. The resident's diagnoses included: Metabolic Encephalopathy, Unspecified Dementia, and Muscle Wasting and Atrophy. Review of the Minimum Data Set (MDS) for Resident #49 dated 09/18/23 revealed in Section C, the Brief Interview of Mental Status was not conducted due to resident is rarely/never understood. In Section G revealed for bed mobility and transfer the resident had 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.

Based on interviews and recorded reviews, the facility failed to develop and implement a PIP (Performance Improvement Plan) in place regarding skin rashes that were monitored using systematic approaches. The findings included: A review of the QAPI (Quality Assurance Performance Improvement) plan provided by the facility's Administrator revealed the following: PIPs are important and meaningful for the specific type and scope of services unique to the facility, which require a concentrated effort on a particular problem in one area of the facility. Our QAPI program will apply systems and reports demonstrating systematic identification, reporting, investigation, and analysis. A project charter will be developed for each PIP at the beginning of the project that clearly establishes the goals, scope, timing, and responsibilities. The PIP charter will be developed by the QAPI committee and then will be given to the team that will carry out the PIP. Review of the facility's policy titled Scabies Identification, Treatment, and Environmental Cleaning, dated 04/01/22, showed the following:…

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 and interviews the facility failed to provide a clean, safe, homelike environment in the laundry room, and in 3 of 72 rooms. The findings included: 1. During an observation conducted on 10/16/23 at 11:10 AM in room [ROOM NUMBER] of a hole in the fitted sheet on the bed (Photographic evidence obtained). 2. During an observation conducted on 10/16/23 at 11:18 AM in room [ROOM NUMBER] of the air conditioning vents were covered with dust (Photographic evidence obtained). 3. During an observation conducted on 10/16/23 at 11:30 AM in room [ROOM NUMBER]-B of a wobbly overbed table. 4. During an observation conducted on 10/16/23 at 1:10 PM in room [ROOM NUMBER], there were two unpainted repairs with plaster to the wall between the window and the bathroom. The air conditioning vents were covered with dust, debris and what appeared to be hair. (Photographic evidence obtained). 5. During a tour conducted of the laundry room on 10/16/23 at 2:00 PM, an observation was made of the following: a) In 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to assess and treat symptoms of itching and rashes in a timely manner for 3 of 9 residents reviewed for skin conditions (Resident #53, Resident #23, and Resident #56). The facility also needed to obtain a urine sample in a timely manner for Resident #42. The findings included: Review of the Center for Disease Control and Prevention (CDC) website, under the section Scabies revealed the following: Scabies outbreaks have occurred among patients, visitors, and staff in institutions such as nursing homes and long-term care facilities. Such outbreaks frequently result from delayed diagnosis and treatment of crusted (Norwegian) scabies in debilitated, immunocompromised, institutionalized, or elderly persons. The characteristic itching and rash of scabies can be absent in such people, leading to frequent misdiagnosis and delayed or inadequate treatment and continued transmission. Scabies often are only recognized once they begin to appear among…

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 provide respect and dignity in a manner and in an environment that promotes enhancement of quality of life that include, ensuring all residents are served proper drinking cups with meals; ensuring residents are served hot meals and/or bagged lunch on scheduled outpatient dialysis center appointments for 2 of 2 sampled residents reviewed for dialysis; and ensuring a residents' nails are not clipped over the lunch meal tray for 1 of 1 sampled residents (Resident #257), who was reviewed requiring fingernail care. The findings included: 1) During the observation of the breakfast meal on 06/21/22 at 8 AM noted that all facility resident's (94) received a carton of milk, carton of juice , and a majority received a nutritional liquid supplement. Further observation noted that none of the facility residents received a proper beverage cup for the residents to drink from. It was further noted that facility residents were required to drink directly from the beverage carton container. Upon interviews with random…

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 provide sufficient staff to carry out the functions of the food and nutrition service, for 94 of the facility's 94 residents. The findings included: 1) Observation of the lunch meal in the main kitchen on 06/22/22 at 11:30 AM noted non-kitchen staff working within the department that included the Director of Medical Records and a CNA. Interview with the Dietary Manager at the time of the meal observation noted to state that the dietary department has been down 2 diet aide positions for some time and often requires staff from other departments to be scheduled in the kitchen on a regular basis. It was also noted that the dinner cook was rescheduled to the breakfast and Lunch meal service on 06/22/22. Further observation of the 06/22/22 lunch meal noted that foods were not prepared on time and the meal service scheduled to start on 11:05 AM did not begin until 12:05 PM. The resident dishes were not finished washing until 12 PM. The lunch meal was delayed for over 90 minutes. 2) During the observation of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determine that the facility failed to provide food prepared by methods that conserve nutritive value, flavor, appearance, and is palatable, attractive, and appetizing temperatures for for all 94 facility resident's that included interviews conducted with 4 (Resident's #93, #251, #256, and #257) of 4 interviews conducted with additional residents. The findings included: 1) During the review of the grievance Logs from January 2022 through May 2022 noted the following resident food grievances: January 2022 = 3 total grievances including: Poor food quality Failure to food preference No meal alternatives available Incorrect food consistency February 2022 = 13 total grievances including: Poor food appearance Poor food quality taste (3) Food preference not followed (5) Cold food temperatures (2) Late tray service Therapeutic diet not followed Assistance with eating Incorrect diet consistency March 2022 = 7 total grievances including: Food Preference not…

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 the residents receive at least three meals daily, at regular times comparable to normal mealtimes in the community. The findings included: 1) During the observation of the lunch tray line assembly in the main kitchen on 06/22/22, it was noted there were staff working in the kitchen who were not dietary personal. Specifically, the Medical Records Director and a CNA were working in the kitchen for the lunch meal preparation and service. Interview with the Dietary Manager at the time of the observation revealed that the kitchen is down 2 full times position and the dinner cook needed to be scheduled for the breakfast meal preparation . Further observation noted that the 06/22/22 lunch tray assembly line began at 12:05 PM. A review of the Meal Tray Delivery Form and observation of meal tray carts noted the following: Hall 100: Scheduled delivery time documented as 11:05 PM - Actual delivery time was recorded at 12:30 PM Hall 500 - Scheduled delivery time documented as 11:45 AM - Actual delivery time was…

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 and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The findings included: 1) During the initial Kitchen/Food Service observation tour conducted on 06/20/22 at 9 AM, accompanied with the Dietary Manager (DM) the following were noted: (a) The floor area leading up to the entry door of the dietary department was heavily soiled, with presence of garbage and trash. This was discussed with the DM that food carts and staff entering into the kitchen are tracking in the dust and dirt from the soiled floor. (b) There were numerous open food trays with visible trash/garbage sitting within the entry area of the kitchen. It was discussed with the DM that all garbage and refuse must be covered at all times to prevent the potential of food borne contamination and illness. (c) The food preparation floor and serving areas were noted heavily soiled with dust, dirt, trash , and garbage. It was discussed with the DM that the kitchen floor is not being cleaned on 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.

Based on record review and interviews, the facility failed to honor 1 of 3 sampled residents' rights (Resident #52) to appeal discharge from skilled services (OT (Occupational Therapy & PT (Physical Therapy), by ensuring they received and signed the Notice of Medicare Non-Coverage (NOMNC). The findings included: Resident # 52 began skilled services on 05/05/2022 and his therapy services were terminated on 06/08/2022. The facility initiated the discharge (d'c) with rehabilitation days remaining. However, review of the Notice of Medicare Non-Coverage (NOMNC) revealed that it was not signed by the resident or his authorized representative. The Social Worker wrote on the NOMNC that Resident #52's authorized representative (AR) was contacted on 6/6/2022 via telephone to let him know that the treatment would be suspended on 06/09/2022. During an interview conducted with the Social Worker (SW) on 06/22/22, at 3:02 PM, she reported that the resident's AR came to the facility for the discharge a few days prior to the discontinuation of the resident's skilled services, and on the day 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that 2 of 3 sampled residents (Resident #14 and #151) received a copy of the Baseline Care Plan. The findings included: 1. On 06/20/22 at 1:35 PM, during an interview with Resident #14, he reported that he did not participate in any care plan meeting and no one discussed his plan of care with him. Review of the clinical record revealed that Resident #14 was diagnosed with the following: Other Symptoms and Signs Involving the Musculoskeletal System Right Artificial Knee Joint, Muscle Wasting And Atrophy, Difficulty In Walking, Complication Of Internal Left Knee Prosthesis, Left Artificial Knee Joint, and Osteoarthritis. Review of the Baseline care plan (CP) dated and completed on 6/11/2022 showed that it was initiated on 6/10/2022. The CP outlined all the required services Resident #14 was supposed to receive during his stay at the facility. Review of the Nurses Progress Notes dated 06/13/2022 revealed an entry that the Rehabilitation Unit Nurse…

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, interview and record review, the facility failed to identify the need for assistance with Activities of Daily Living (ADL) for fingernail care for 6 of 6 sampled residents reviewed for Activities of Daily Living, Resident #19, Resident #42, Resident #80, Resident #258, Resident #55 and Resident #257, as evidenced by the residents fingernails were observed to be unclean and in varying stages of excessive length. The findings included: Review of the facility policy for Nail Care states in part, 'Purpose: To provide for personal hygiene needs and prevent infection. Note: Precaution should be used when trimming nails of a patient with diabetes and should be done by a licensed nurse or physician. Procedure: Trim nails and file for smoothness, as needed.' Review of the facility policy and procedure on 06/22/22 at 2:22 PM for Nail Care provided by the Director of Nursing (DON) revised 01/2014 indicated Purpose: To provide for personal hygiene needs and prevent infection. Note: Precaution should be…

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 and interview, the facility failed to ensure that 1 of 1 sampled residents (Resident #255), reviewed for dialysis, received treatment and care in accordance with professional standards of practice that includes medications administered, as per physician orders. The findings included: During the review of the clinical record of Resident #255, it was noted an admission date of 06/07/22 with diagnoses of End Stage Renal Disease, Dependence on Dialysis and DM-2. Further review of physician orders noted 06/08/22, Sevelamer 800 mg (2 Tabs) Phosphorus Binder- Three time per day for Kidney Disease. Further review of the record and interview with the Unit Manager on 06/21/22 noted that the resident's dialysis days are scheduled for Monday, Wednesday,and Friday. Upon admission the resident's original chair time was scheduled for 10:30 AM and was changed on 06/15/22 to 12:30 PM. The resident returns from dialysis days during the late afternoon hours of 4-5 PM. A review of the June 2022 - Medication…

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, interview and record review, the facility failed to ensure splint devices were applied, as recommended for 1 of 2 sampled residents reviewed for Position/Mobility, Resident #301, as supported by no evidence bilateral hand palm guards were applied for Resident #301. The findings included: Review of the facility Restorative Nursing Guideline policy states in part, 'Overview: Restorative nursing care includes nursing interventions that help to maintain the patient's highest level of function and prevent unnecessary decline in function. Restorative nursing programs are individualized to specific patient needs and have many tangible positive effects including - preventing further decline Patients may enter a restorative nursing program in several ways including after discharge from a skilled physical, occupational or speech rehabilitation program.' Review of the clinical record for Resident #301 revealed she was admitted to the facility on [DATE] with diagnoses to include Cerebral Vascular…

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, interview and record review the facility failed to appropriately assess and manage pain for 1 of 1 residents reviewed for Pain Management, Resident #258, as evidenced by Resident #258 expressing little to no relief of pain with the current pain management regimen. The findings included: Review of the facility policy for Pain Management Guidelines states in part, 'Purpose: To describe the process steps required for interventions to prevent and or manage both acute and chronic pain. Guidelines: Pain is a highly subjective and personal experience which is impacted by one's previous experiences with pain as well as by cultural and spiritual beliefs. Pain is evaluated and documented - Before and after administration of PRN (as needed) pain medication; Prior to initiating therapy interventions; Prior to initiating wound care treatments; Using an appropriate pain scale, determined by nursing. Numeric Rating Scale: Used for patients whose cognitive functioning ranges from intact to mildly 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 observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure that it 1) secured and locked the un-ordered expired over-the-counter prescription medication for 1 of 1 residents, Resident #96, 2) failed to ensure that it secured and locked an un-ordered over-the-counter (OTC) and an expired prescription medication for Resident #9, 3) failed to secure prescription medications left at the bedside for Resident #11 and 4) for Resident #39. And, 5) Licensed nurse was observed pre-pouring medication on unit on [DATE] for a resident, during an observational room tour. The findings included: 1) During an initial observational tour conducted on [DATE] at 10:53 AM, Resident #96 was noted to have a half-used tube of prescription Triamcinolone Acetonide Cream 0.1% (expiration date of 03/23 with the name of a different resident who expired in the facility over two (2) months ago back on [DATE]), in Resident #96's bathroom, on a shelf, unlocked,…

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.