Jupiter Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observations, record review and interviews, the facility failed to ensure that it was free of medication errors for 3 of 7 sampled residents, as evidenced by a medication error rate of 15.6% with 32 opportunities due to failure to ensure that Resident #7 received medications ordered and was available for him, failure to ensure Resident #5 received medications that are prescribed to him, failure to notify the physician prior to holding blood pressure medications for Resident #27.The finding Included:The facility policy titled Medication Administration documented in part Policy Explanation and Compliance Guidelines 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters. 12. Compare medication source (bubble pack, rectal, etc.) with medication administration record (MAR) to verify resident name, medication name, form, dose, route, and time. (photographic evidence…

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 obtain a laboratory test for 1 of 5 sampled residents reviewed for laboratory testing. (Resident #8). The findings included: A review of the clinical record for Resident #8 revealed the resident was admitted to the facility on [DATE], with diagnoses of Anxiety Disorder, Depression, and Psychotic Disorder. A physician's order on the same day specified that Divalproex Sodium Oral Tablet Delayed Release 125 mg should be administered orally twice daily for mood disorder. Additionally, the physician ordered a valproic acid level to be measured on 06/01/2025. However, the records lacked documented evidence of the valproic acid test result.On 07/10/2025 at 12:29 PM, an interview was conducted with the Director of Nursing (DON), during which a side-by-side review of Resident #8's records occurred. The DON acknowledged the absence of the valproic acid result and promptly contacted the Unit Manager, requesting a follow-up with the laboratory service regarding…

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 policy review, observation, record review, and interview, the facility failed to ensure infection control practices for 3 of 30 sampled residents, as evidenced by the failure to abide by Transmission Based Precaution (TBP) guidelines, Enhanced Barrier Precaution (EBP guidelines, and failure to use Personal Protective Equipment (PPE) during direct care, for Resident #75, #288 and #71.The findings include:Review of the polices titled, Transmission-Based (Isolation) Precautions (TBP) and Enhanced Barrier Precautions (EBP) showed that the TBP policy documented, in part, 1. Facility staff will apply TBP….to residents who are known or suspected to be infected….3. (b). The provision of a private room as available/appropriate. 4. Residents… should remain in their rooms except for medically necessary care. The EBP policy documented, in part, targeted gown and gloves use during high contact resident care activities. 2.b. An order for EBP will be obtained for residents with any of the following (b)…. wounds,…

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 and interview, the facility failed to have an effective pest control program. The findings included: During the initial kitchen tour, on 07/07/25 at 9:11 AM with the Food Service Director/Certified Dietary Manager (CDM), the following were noted: 1. In the hot holding area of the kitchen, two live and mature roaches were observed on a table by the conveyor toaster.2. In the food service area (where staff collect the plates from the cooks and place in the carts to take to the units and the Main Dining Room) live roaches, in all stages of life and too numerous to count were observed behind a cart containing a stack of trays and single service items (sugar packets, condiments, tea bags etc.) At the time of the observation, the CDM instructed staff to remove the cart, dispose of the single service items, clean and sanitized the cart and the trays that were stacked in the cart. On 07/10/25 at 12:35 PM, the Surveyor attempted to contact the pest control company that provided services to the facility and a voice message was left. There was no response from the pest…

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 nursing staff failed to follow prescribed parameters including blood sugar and blood pressure results for 2 of 4 sampled residents (Resident #1 and Resident #5). The findings included: 1) Clinical record review revealed Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including Diabetes. The Minimum Data Set assessment with reference date of 12/27/24 revealed the resident was assessed as moderately impaired for skills of daily decision making and is receiving insulin and hypoglycemic medications. A review of a Care plan dated 12/21/24, documented Resident #5 has Diabetes Mellitus with Hyperglycemia. The interventions included: Diabetes medication as ordered by doctor and monitor and document for side effects and effectiveness. Review of Physician's order dated 01/23/25, documented Insulin Lispro subcutaneous solution pen injector, 100 units per milliliter, Inject 2 units subcutaneously before meals for Hyperglycemia. Hold for glucose less than…

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 coordinate medication administration times with dialysis services for 2 of 3 sampled residents reviewed (Residents #1 and #6). In addition, the facility failed to ensure the completion of dialysis communication records to validate continuity of care for Resident #1. The findings included: 1a) Clinical record review revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation services. Resident #1's pertinent diagnoses included End Stage Renal Disease, Metabolic Encephalopathy and Diabetes. Medication Administration Records (MAR) dated 05/2024 and 06/2024 indicated Resident #1 did not receive the following medications as prescribed. The explanation documented by the nursing staff noted, Resident in Dialysis: On 06/08/24 Calcium Acetate 667 mg, Ipratropium Nebulizer and Zinc 220 mg. On 06/04/24 Megestrol Acetate Suspension 40 MG/ML, give 5 ml by mouth one time a day for poor appetite for 3 Days. On 05/25/24 Calcium Acetate (Phos Binder)…

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 policy review, record review and interview, the facility failed to ensure licensed nurses were able to demonstrate competency related to following physician's orders for medication administration and documentation for 1 of 3 sampled residents (Resident #1). The findings included: Facility policy titled, Administering Medications, last revised April 2019 documents as follows: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c.…

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 4) A medication pass observation with a random resident, who asked to remain confidential, was made on 03/27/24. Upon entering the room, the surveyor introduced herself and explained she was observing the nurse. The resident stated, The nurses are great, but you need to check up on the CNAs (Certified Nursing Assistants). On 03/27/24 in the afternoon, when asked what was meant by check up on the CNAs, the random resident stated, Some are great, but some have such attitudes. They don't care. I treat them with respect and expect the same from them, but don't always get it. The resident stated, Some act as if they don't want to be here. I know it's a tough job, but it is their job. And they don't let us know they are the CNA for the shift. The resident explained that the nurses come around at the beginning of each shift and let them know they will be the nurse for the shift. Review of the record revealed the resident was cognitively intact, as per a recent Brief Interview for Mental Status (BIMS) score of 15, 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 consider the views of the resident council group and act promptly upon the grievances and recommendations of the group concerning issues of resident care and life in the facility for 9 of 9 sampled residents interviewed during the Resident Council meeting (Resident #47, #45, #8, #10, #58, #63, #33, #70, and #7). This failure has the potential to affect all residents in the facility, as the resident council represents all residents. The findings included: On 03/27/24 at 11:01 AM, interviews were conducted with 9 active, alert and oriented members of the Resident Council (Resident # 47, #45, #8, #10, #58, #63, #33, #70, and #7). The 9 resident council members were asked about the facility's response to grievances voiced by members of the Resident Council during their monthly meetings. All of the resident council members agreed that several grievances were voiced during the monthly Resident Council meetings, but none of these grievances had been resolved by the facility's administration. Three of the council members who…

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 maintenance and housekeeping services to maintain a clean, comfortable and homelike environment on 3 of 4 units (100 Unit, 300 Unit and 400 Unit). The findings included: In room [ROOM NUMBER], the room smelled of urine. It was difficult to tell from which bed the urine smell was coming from. The urine smell was strong around each of the 3 beds in the room. The floor appeared to be dirty and there was debris observed underneath bed B. In room [ROOM NUMBER], the vinyl on the arms of the resident's wheelchair in bed B was cracked and partially missing. In room [ROOM NUMBER], the surface of the foot board of bed A was worn in a manner that the material under the surface was exposed. In room [ROOM NUMBER], the surfaces of the headboard, foot board and nightstand to the resident's right side of the bed was worn in a manner that the material under the surface was exposed. In room [ROOM NUMBER], the surface of the over bed table for bed…

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: 1) Ensure that all voiced grievances made by residents to staff are put in writing on a grievance form and submitted to the appropriate person for resolution for 9 of 9 resident council members interviewed; 2) Ensure all written grievances include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 9 of 9 resident council members interviewed; 3) Ensure prompt efforts are made to resolve grievances voiced by 1 of 1 resident who had concerns regarding the roommate's television being on all day and night (Resident #13). The findings included: The facility's Policy 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 reviews, the facility failed to store, prepare and serve foods in a sanitary manner, in accordance with professional standards for food safety. The findings included: 1). During the initial kitchen tour, on 03/25/24 at 8:44 AM, accompanied by the Dietary Manager, the following were noted. a. The blade of the can opener was noted to have food residue and the surface of the blade was peeling. b. Staff were observed using a damp cloth to wipe the lid of Cambro containers. c. There was an accumulation of ice on the cooling unit and on top of boxes of products that were stored directly under the cooling unit in the walk in freezer. d. The handles of knives were damaged to a point that made them uncleanable non-food contact surfaces. e. Raw shell eggs were stored over pasteurized shell eggs in walk-in refridgerator. f. Staff H, Dietary Aide, was observed rinsing towels in the only hand washing sink in the food service area and leaving food residue in the basin. g. Staff I,…

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 honor preferences for 3 of 8 sampled residents (Resident #159, #161 and #74). The facility failed to respond to a verbal request for side rails to assist with bed mobility for Resident #159. Shower preferences and schedules were not followed for Resident #161 and #74. The findings included: 1) During an interview on 03/25/24 at 12:19 PM, Resident #159 stated she had been asking for a bed side rail since she was admitted to the facility. The resident stated she wanted it to assist her with turning in bed and that she had been asking everyone for it. Observation of the bed at that time lacked any type of side rail or mobility device. During a supplemental interview on 03/27/24 at 3:28 PM with the resident and her family, they all confirmed the resident had been asking for a bed side rail since day one. Review of the record revealed Resident #159 was admitted to the facility on [DATE]. Review of the Admission/readmission Evaluation dated…

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 update care plans related to nutrition interventions for 1 of 29 sampled residents (Resident #60), and Hospice status for 1 of 29 sampled residents (Resident #43). The findings included: 1) Resident #60 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #60 had a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. The MDS documented that Resident #60 required 'Supervision or touching assistance' for eating. Resident #60's diagnoses at the time of the MDS included: Anemia, Quadriplegia, Traumatic Brain Injury, Malnutrition, Cognitive Communication Deficit, COPD (Chronic Obstructive Pulmonary Disease), Dysphagia, and History of Healed Traumatic Fracture. Resident #60's dietary Orders included: Regular diet, Mechanically Altered Ground texture, Nectar Thickened Liquids consistency - Fortified…

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 thoroughly investigate a fall for 1 of 2 sampled residents (Resident #13) reviewed for falls. The findings included: Review of the record revealed Resident #13 was admitted to the facility on [DATE], and was transferred to her current room on 02/17/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented Resident #13 had a history of a fall with a fracture prior to her admission, and that she needed partial to moderate assist for both toileting and walking. A fall risk assessment dated [DATE] documented the resident was at moderate risk for falls. Review of the current care plan initiated 01/29/24 documented the resident was at risk for falls and staff were to provide toileting assistance as per the resident's needs and therapy recommendations.…

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, record review, interview, and policy review, the facility failed to ensure indwelling catheter bags remained off the floor for 3 of 4 sampled residents (Resident #61, #83, and #50); and failed to ensure staff documented the monitoring of input and output of fluids, as per physician orders, for 1 of 4 sampled residents (Resident #50). The findings included: Review of the policy Urinary Catheter Care revised August 2022 documented, Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Care: . 4. Be sure the catheter tubing and drainage bag are kept off the floor. 1) Review of the record revealed Resident #61 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had an indwelling catheter and had an urinary tract infection in the past 30 days. Current orders documented staff were to empty, record and monitor the nephrostomy tubes…

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, record review, and interview, the facility failed to ensure proper care and services for a peripheral intravenous (IV) line for 1 of 1 sampled resident (Resident #61). The findings included: Review of the record revealed Resident #61 was admitted to the facility on [DATE]. Review of the current orders lacked any order for an intravenous line, although discontinued orders revealed the resident received an IV medication for three days as of 03/22/24. Review of current care plans lacked any evidence, related to an IV line. During an attempted interview and observation on 03/25/24 at 3:18 PM, Resident #61 was unable to answer any questions. A peripheral IV line was noted to his right forearm dated 03/17/24 (Photographic Evidence Obtained). A supplemental observation on 03/26/24 at 3:37 PM revealed the same IV line dated 03/17/24. The Director of Nursing (DON) was made aware of the peripheral IV line for Resident #61. When asked the process for the peripheral lines, the DON stated they 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 policy review, observation, interview and record review, the facility failed to conduct respiratory assessment with nebulizer treatment per facility policy for 1 of 1 sampled resident reviewed for respiratory concerns (Resident #29) The findings included: Policy review titled, administering medications through a small volume (handheld) nebulizer. Dated October 2010. The policy revealed the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Steps in the procedure included: #6. Obtain baseline pulse, respiratory rate and lungs sounds. #15. Instruct the resident to take deep breath, pause briefly and then exhale normally. #26 obtain post-treatment pulse, respiratory rate and lungs sounds. #27 rinse and disinfect the nebulizer equipment according to facility protocol, or wash pieces with warm, soapy water, rinse with hot water. Record review revealed Resident #29 was initially admitted to the facility on [DATE] and re-admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure proper monitoring of blood sugars as evidenced by the failure to notify the physician of blood sugar levels greater than 250, as per physician order, for 1 of 5 sampled residents (Resident #13). The findings included: Review of the record revealed Resident #13 was admitted to the facility on [DATE]. Review of the current orders revealed as of 01/31/24 staff were to obtain and record the blood sugar level for Resident #13 twice daily before breakfast and dinner, and notify the physician if the blood sugar reading was less than 70 or greater than 250, for diabetic monitoring. Review of the March 2024 Medication Administration Record (MAR) and corresponding progress notes revealed the following blood sugar levels that were greater than 250, and the physician was not notified: On 03/01/24 at 4:30 PM the blood sugar reading was 260. On 03/02/24 at 4:30 PM the blood sugar reading was 317. On 03/03/24 at 4:30 PM the blood sugar reading was 346. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to honor resident's food preference for 1 of 10 sampled residents reviewed for food concerns (Resident #25). The findings included: Resident #25 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. On 03/25/24 at 10:20 AM, Resident #25 stated that all he gets for breakfast is sausage, sausage, sausage! He stated he would really like some bacon and ham sometimes, not always sausage. On 03/25/24 at approximately 11:30 AM, the Registered Dietitian was informed of Resident #25's request for more variety in choice of breakfast meats. She stated she would speak with the Resident to try to accommodate his request. A review of a Dietary Note dated 03/25/24 at 1:33 PM documents: Met with resident. He is requesting bacon at breakfast time. Explained bacon in relation to therapeutic diet and diet consistency. Resident verbalized understanding and requested to receive…

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 4) Review of the record revealed Resident #32 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating he was cognitively intact. This MDS also revealed Resident #32 needed extensive to total assistance of one to two persons for all Activities of Daily Living (ADLs). During an interview on 12/13/22 at 11:33 AM, Resident #32 was asked about the food at the facility and explained he had been asking for cold cereal for breakfast and the nurses said it's too far away (for them to get it). During this continued interview at 11:38 AM, when asked if he was treated with respect and dignity, Resident #32 stated, The CNAs (Certified Nursing Assistants) are lazy. When asked why he said that, the resident explained when you ask for something like assistance they say, you can do it. When asked how that makes you feel, Resident #32 stated, like there is 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 facility policy, interview, and observation, the facility failed to provide hot water for showers for 3 Residents (#82, #84 and #52); failed to maintain resident room doors for 3 Residents (#71, #19, and #52); and failed to ensure a clean and comfortable environment on 3 of 4 resident units (unit 200, unit 300 and unit 400). The findings included: Facility Policy titled TELS Policy on How to Submit a Work Order dated 08/01/2022 documents, It is the policy of [NAME] Rehab and Healthcare that in the event that a repair or routine maintenance needs to be made in the facility, staff members should fill out a work order in the TELS system for the Maintenance department to follow up with the repair. 1) On 12/12/2022 at 12:21 PM Resident #82 stated she wanted a shower, but the shower does not get warm. She stated it is ice cold and she cannot take a shower that way. On 12/13/2022 at 10:40 AM and 12/14/2022 at 1:00 PM Resident #82 stated they still do not have hot water in the shower, and they have not had hot…

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 accuracy of the MDS assessment for 3 of 5 sampled residents. This concern involved Resident #98, #21, and #52. The findings included: 1) Record review revealed Resident #21 was initially admitted to the facility on [DATE], with a re-admission on [DATE]. The 5-day minimum data set (MDS) assessment, reference date 12/05/22, indicated a brief interview for mental status score (BIMS) of 14, indicated Resident #21 was cognitively intact. Additional review of the MDS was conducted under section N for medication, subsection H for Opioid usage, it was revealed that the MDS was coded in error, the MDS coded 5, as an indication the Opioid was administered 5 times on the 7 days look back period. Review of the November and December medication administration records (MARs) showed the medication was administered 6 times on the 7 days look back period from 11/29-12/05/22. On 12/15/22 at 9:21 AM a side-by-side review of Resident #21's records and an interview…

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 facility policy, observation, interview, and record review, the facility failed to provide quality of care for 6 of 29 sampled residents reviewed. The facility failed to investigate conflicting medication orders on admission for Resident #92, failed to obtain stool for occult blood for Resident #82, failed to obtain consults in a timely manner for Resident #84 and #20, failed to maintain and utilize an indwelling blood sugar monitoring device as ordered for Resident #71, and failed to ensure diabetic ulcer wound care for Resident #93. The findings included: Facility policy, titled, admission Criteria dated 11/30/22 documented, Our facility admits only residents who's medical and nursing care needs can be met. Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: medication orders, including (as necessary) a medical condition or problem associated with each…

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 notify the family of a significant change of 1 of 1 sampled residents, Resident #75. The findings included: During a telephone interview on 12/13/22 at 8:09 AM with Resident #75's daughter, she stated that she was very upset because she was never notified that her mother had declined and that they put a foley catheter and pic line in her. Record review for Resident #75 revealed she was admitted to the facility on [DATE] with a diagnosis to include Dementia, Hypertension, Acute Kidney Failure, Heart Failure, Major Depressive Disorder, Anxiety Disorder, Dysphagia, Cardiomegaly, Metabolic Encephalopathy and Cirrhosis of the Liver. A review of the MDS (Minimum Data Set) documents she has a BIMS (Brief Interview Mental Status) of a 1 which means her cognition is severely impaired. Her Power of Attorney is her daughter. A review of the progress notes documents the following and does not mention notifying the daughter of change in condition: On 11/06/22 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, record review and interview, the facility failed to ensure activities were provided, failed to ensure an accurate activity care plan was completed, which the resident's may have benefited from one-on-one activities for 2 of 2 sampled residents reviewed for activities (Resident #55 and Resident #75). The findings included: 1) During observations throughout the recertification survey from 12/12/22 through 12/15/22 Resident #55 and Resident #75 were never seen out of bed. There were no activities ever observed to be done with these residents. 1) Record review of Resident #55 revealed he was admitted to the facility on [DATE] and in November 2022 was placed on hospice services. His diagnoses to include Parkinson's Disease, Anxiety Disorder, Rhabdomyolysis, Cerebral Infarction, and Dysphagia. His most current MDS (Minimum Data Set) assessment for Significant Change for hospice services on 11/09/22 documented he has a BIMS (Brief Interview for Mental Status) score of a 4, which means his…

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, record review, and interview, the facility failed to ensure the provision of podiatry services for 1 of 2 sampled residents (Resident #52). The findings included: During an interview and observation on 12/12/22 at 3:45 PM, Resident #52 stated she had not seen the podiatrist in a few months. The resident stated she was a diabetic and needed her nails trimmed. With permission of the resident, an observation was made and all the resident's toenails were elongated and needed to be trimmed. Review of the record revealed Resident #52 was admitted to the facility on [DATE] with diagnosis to include diabetes with neuropathy. Further review of the record revealed the last podiatry visit for Resident #52 was on 05/27/22. The current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also revealed the resident was a diabetic. During an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nutritional service (supplements and weight monitoring), as ordered by the physician and as recommended by the Registered Dietitian for 2 of 5 sampled residents reviewed. This involved Resident #97 and #16. The findings included: 1) Review of Resident #97's record revealed, she was admitted to the facility on [DATE], with diagnoses that included: Non-Alzheimer's Dementia, and Malnutrition. The modification 5 day minimum data set (MDS) assessment, reference date 11/08/22, recorded a brief interview for mental status score (BIMS) score of 04, indicating Resident #97 was cognitively impaired. This MDS showed documented evidence that Resident #97 had received Parenteral/IV feeding (IV fluids) while in the facility for low sodium level. The MDS recorded Resident #97 required extensive assistance with eating. Review of physician order dated 10/24/22 indicated to monitor weekly weight times 4, every Monday for 4 Weeks. Review of Resident #97's records…

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.