Lanier Rehabilitation Center

Based on kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility kitchen staff failed to follow proper dish sanitation procedures, wash their hands between glove changes, and to allow for air drying after washing dishes to prevent the outbreak of foodborne illness. Hand hygiene, dish sanitation, and air drying is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe sanitation practices represent a potential source of pathogen exposure. The findings include: During the initial kitchen tour on 2/17/2025 at 9:25 AM, the hand sink did not have soap in the soap dispenser. On 2/17/2025 at 9:27 AM, an observation of the dish room and dish washing processes revealed Dietary Aide (DA) J loading the dish machine and running it. The dish machine temperature gauge was observed during the wash cycle and the rinse cycle. The temperature for each cycle did not rise above 69 degrees Fahrenheit…

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, a review of resident records, and the Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to implement it's performance improvement plan's (PIP) corrective actions to reduce the risk of falling for one (Resident #64) of four residents reviewed for falls, from a total survey sample of 27 residents. The findings include: An observation of Resident #64 on 2/17/25 at 10:03 AM found her lying on the far left side of her bariatric bed (a hospital bed designed for obese individuals) on the edge of the mattress. There was no bed rail or enabler in place. The room was decorated with multiple personal items on the left side of the bed on the floor and bedside table. A reacher/grabber tool was observed on a chair against the far wall at the foot of the bed, out of her reach. There were no fall mats and no signs posted in the room. (Photographic evidence obtained) Resident #64 explained that she had four falls but was unaware of any…

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 kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility failed to ensure that all mechanical equipment in the kitchen was maintained in safe operating condition. The water heater for the kitchen was not operating, thereby the dish machine temperatures failed to reach the appropriate levels. Failure to ensure the dish machine wash and rinse temperatures reached the proper temperature required by the manufacturer's specifications may result in the risk of serious complications from foodborne illness. The findings include: During the initial kitchen tour on 02/17/2025 at 9:27 AM, observation of the dish room and dish washing processes revealed that Dietary Aide (DA) J was loading the dish machine and running it. The dish machine temperature gauge was observed during the wash cycle and the rinse cycle. The temperature for each cycle did not rise above 69 degrees Fahrenheit ('F). The Certified Dietary Manager (CDM) stated it was a low temperature machine and it used chlorine bleach to sanitize 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 resident interviews, Resident Council (RC) minutes review, staff interviews, and facility policy and procedure review, the facility failed to 1) Ensure that the Dietary Manager attended the February 2025 meeting at the group's invitation to discuss food concerns, 2) Ensure issues of resident care and life in the facility were addressed by failing to review resident rights and inform residents of updates to the facility's policies and procedures, even though Resident Council forms were marked as though they had. The findings include: During an interview on 02/17/25 at 11:55 AM with the Resident Council President, Resident #23, and Resident #56, who both attend the meetings on a regular basis, Resident #23 stated he did not get to read the Resident Council minutes. He did not sign off on them to verify whether or not they were correct. He did not receive copies of the minutes. He stated usually the staff from the Activities Department attended the meetings and took the minutes. The Activities Director…

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 a review of resident records, observations, resident and staff interviews, and a review of facility policies and procedures, the facility failed to implement the person-centered care plan to meet residents' assessed needs for fall prevention for one (Resident #64) of four residents reviewed for falls, from a total survey sample of 27 residents. The findings include: A review for Resident #64's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included personal history of traumatic brain injury, lack of expected normal physiological development in childhood, mood disorder due to known physiological condition, abnormalities of gait and mobility, generalized muscle weakness, osteoarthritis of knee, major depressive disorder, anxiety disorder and obesity. A review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #64 had a brief interview for mental status (BIMS) score of 15/15 points, indicating that she was cognitively intact…

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 a review of resident records, observations, resident and staff interviews, and a review of facility policies and procedures, the facility failed to 1) Ensure resident rooms were free of accident hazards per the plan of care, and ensure assistive devices were available to prevent accidents for one (Resident #64) of four residents reviewed for falls, and 2) Ensure residents' safe use and storage of personal cleaning products to prevent accidental access by other residents for one (Resident #24) of five residents reviewed for environmental safety, from a total survey sample of 27 residents. The findings include: 1. A record review for Resident #64 revealed that she was admitted to the facility on [DATE]. Her diagnoses included a personal history of traumatic brain injury, lack of expected normal childhood physiological development, mood disorder, abnormalities of gait and mobility, generalized muscle weakness, osteoarthritis of knee, major depressive disorder, anxiety disorder and obesity. A review 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.

Based on interview and record review, the facility failed to inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident became eligible for Medicaid of (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section for three of three residents randomly selected for review of Beneficiary Notification Review. The findings include: An Entrance Conference was conducted with the Administrator and Director of Nursing on 4/3/2023 at 9:45 a.m. They were asked to provide a list of the residents who were discharged from a Medicare Part A-covered stay with benefit days remaining in the last six months. On 4/4/2023, the Administrator advised that 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, the facility failed to provide a safe, clean, comfortable, and homelike environment as well as housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for the 94 residents in its census, facility staff and visitors. The findings include: During a tour of the facility on 4/3/2023, multiple walls and flooring tiles in the halls on the units were observed to be in need of repair. Chipped paint, broken baseboards, stained floors, and broken tile were also observed. Resident rooms were in need of repair and/or cleaning, with resident room doors observed to be splitting and in need of repair as follows: At 11:34 a.m., the bathroom in room [ROOM NUMBER] was observed. The faucet was loose from the sink during water temperature testing. The the wall behind the sink had been patched with a thick substance, which had not been sanded down prior to being repainted. A large watermark stain was observed above the resident's…

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 accurately assess a resident's requirements for assistance to eat for one (Resident #44) of one residents reviewed for nutrition, from a total of 32 residents in the sample. The findings include: Review of the medical record for Resident #44 revealed an admission date of 6/29/2021. Medical diagnoses included dementia, protein-calorie malnutrition, and primary osteoarthritis of the right and left wrists. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 99, indicating the resident was unable to complete the interview. The assessment identified the resident as requiring supervision to eat. On 08/09/21 at 12:33 PM, Resident #44 was observed sitting in her geri-chair in her room. Her tray table was positioned in front of her. Her lunch meal was on the tray table. Spaghetti was on the plate. Resident #44 was observed picking up one spaghetti noodle from her plate using her right…

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 provide appropriate nutritional services by failing to provide assistance to eat for one (Resident #44) of two residents reviewed for nutrition, from a total of 32 residents in the sample. The findings include: A review of the medical record for Resident #44 revealed an admission date of 6/29/2021. Medical diagnoses included dementia, protein-calorie malnutrition, and primary osteoarthritis of the right and left wrists. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 99, indicating the resident was unable to complete the interview. The assessment identified the resident as requiring supervision to eat. On 08/09/21 at 12:33 PM, Resident #44 was observed sitting in her geri-chair in her room. Her tray table was positioned in front of her. Her lunch meal was on the tray table. Spaghetti was on the plate. Resident #44 was observed picking up one spaghetti noodle from her plate…

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, staff interview and policy and procedure review, the facility failed to adequately monitor laboratories as ordered by a physician for one (Resident #15) of five residents reviewed for unnecessary medications, from a total of 32 residents in the sample. The findings include: A medical record review for Resident #15 revealed she was admitted on [DATE], with the following diagnoses: dementia with Lewy body, delusional disorder, histrionic personality disorder and generalized anxiety disorder. A review of Resident #15 current physician orders dated 6/4/21, revealed complete blood count (CBC), comprehensive metabolic panel (CMP), glycated hemoglobin (A1C), thyroid-stimulating hormone (TSH) and valproic acid test (VPA) every night shift every 3 months, starting on 7th for 1 day for prophylaxis. (Copy obtained) There was no documentation in the medical record for Resident #15 that the above-mentioned laboratory orders were completed. The previous CBC, CMP, A1C, TSH and VPA were completed on…

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.