Medicana Nursing And Rehab Center

Based on observations, interviews and record reviews, the facility failed to have an effective pest control program. The findings included: During a tour of the kitchen, on 09/10/25 at 8:50 AM, accompanied by the Dietary Manager, the following were noted: * One live and mature roach was observed on the door frame at the entrance to the janitorial closet.* One live and mature roach was observed in a container where a bag of sauce was stored.* Live mature and juvenile roaches, too numerous to count, were observed under the steamer around a floor drain where there was an accumulation of debris and residue.* Live mature and juvenile roaches were observed on the floor under and around the hand washing sink and the beverage station that were adjacent to each other. During an interview at the time of the observation, the Dietary Manager stated that the pest control company had just come out and treated the kitchen last week. The Dietary Manager stated, We do it every month (referring to the pest control company servicing the kitchen). Review of the most recent pest control invoices, 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 observation, interview and record review, the facility failed to ensure personal privacy during medical treatment, of a med (medication) pass for 1 out of 6 sampled residents reviewed for med pass, affecting Resident #88. The findings included: Review of the facility's policy titled, Resident Dignity and Property Privacy with an effective dated of 04/2024, included in part, the following: The center provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. Fundamental Information Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth. Each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Procedure: 2. Examine and treat residents in a manner that maintains their privacy. a. Use a closed door, a curtain drawn, or both to shield the resident during…

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 develop a care plan for 2 of 2 sampled residents, with a diagnosis of Post-Traumatic Stress Disorder (PTSD), affecting Resident#1 and #86. The findings included: Review of the facility's policy titled, Comprehensive Person-Centered Care Plans with a revised date of 08/2023, included in part, the following: The center will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Fundamental Information The comprehensive care plan will describe the following: 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required are provided to the resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 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 record review and interview, the facility failed to ensure antibiotics were administered as ordered for 1 of 3 sampled residents, reviewed for antibiotic therapy (Resident #60). The findings included: Resident #60 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment and was dependent for activities of daily living. a). Review of Resident #60's orders revealed an order dated 12/03/24 for Ertapenem (antibiotic) 1 gram intravenously (IV) every 24 hours for a multi drug resistant organism (MDRO) in the urine for 9 days. The antibiotic order was reduced to 7 days (until 12/10/24) on 12/05/24 per antibiotic stewardship suggestion. Review of Resident #60's medication administration record (MAR) revealed the resident received 8 doses of antibiotics in 7 days (given twice on 12/04/24). b). An order dated 12/15/24 for Ceftriaxone (an antibiotic) was ordered for 1 gram every 24 hours for 5 days for an elevated white blood cell…

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 ensure smoking evaluations were completed for 2 of 9 sampled residents identified as smokers (Residents #66 and #75). The findings included: The facility's policy titled Smoking effective 10/24/22 and revised 09/23 revealed Residents that are active smokers will be identified on admission and reviewed when there is a significant change of status, quarterly, and annually thereafter. 1). Resident # 75 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Myalgia, and Type 2 Diabetes Mellitus. Her Brief interview for Mental Status (BIMS) score was 15 on the quarterly Minimum Data Set (MDS) with an assessment reference date of 12/28/24. This indicated the resident is cognitively intact. Record review revealed on 04/26/24 Resident #75 had a safe smoking evaluation. On 10/31/24 the resident had another smoking evaluation. There were no additional smoking evaluations. The resident did not have a smoking…

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 physician visits were conducted within the required time frame, for 1 of 18 sampled residents (Resident #66). The findings included: Record review for Resident #66 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included, in part, the following: Bullous Pemphigoid, Venous Insufficiency (Chronic Peripheral), Elevated [NAME] Blood Cell Count Unspecified, Morbid (Severe) Obesity, Tobacco Use and Chronic Gout. Review of the Minimum Data Set Assessment for Resident #66 dated 01/03/25 documented in Section C, a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician/Practitioner Progress Note for Resident #66 from 01/01/24 to 01/12/25 revealed the following: On 01/22/24 written by Staff F Primary Physician. On 03/19/24 written by Staff F Primary Physician, which documented in part the following: Visit performed by 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 record review and interview, the facility failed to coordinate care with hospice services for 1 of 1 sampled resident reviewed for hospice (Resident #13). The findings included: Record review revealed Resident #13 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and was dependent for activities of daily living. The assessment further documented the resident was receiving hospice services. A review of Resident #13's orders revealed the resident was admitted to hospice services on 11/15/24. Resident #13 was care planned for hospice services. An intervention included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. A review of Resident #13's hospice record, located in the facility's hospice binder at the nurse's station, revealed missing hospice documentation. Resident #13's binder only included the initial certification for hospice 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.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct an identified quality deficiency in the problem area as evidenced by repeated deficient practice for F656, Comprehensive Resident Centered Care plan. This repeated deficient practice had the potential to affect all 85 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed the facility was cited at F656, (Comprehensive Resident Centered Care Plan), during the Recertification and Relicensure survey with an exit date of 09/14/23. Review of the QAPI program with the Administrator revealed the lack of an effective corrective action plan for the above deficiency. During an interview with the facility's Administrator on 01/16/25 at 2:43 PM, the Administrator was apprised that this deficiency would be cited on the current survey. This was acknowledged by the Administrator.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow up for a Vancomycin Resistant Enteroccocus (VRE) (a multi-drug resistant organism) infection and precautions for 1 of 3 sampled residents reviewed for antibiotic therapy (Resident #60), and failed to wear appropriate personal protective equipment (PPE) during of care of resident on enhanced barrier precautions (EBP) (Resident #71). The findings included: 1). Record review revealed Resident #60 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment and was dependent for activities of daily living. Record review revealed Resident #60 was on enhanced barrier precautions for ESBL (a multi-drug resistant organism) in the urine from 12/03/24 - 12/11/24. A review of Resident #60's orders revealed an order dated 12/14/24 for a urinalysis culture and sensitivity. The culture was reported positive for VRE (a multi-drug resistant organism) on 12/18/24. An order…

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 have an effective antibiotic stewardship program for 2 of 3 sampled residents reviewed for antibiotic therapy (Residents #60 and #62). The findings included: A review of the facility's policy titled Antibiotic Stewardship, dated 10/24/17, documented: The facility will establish a multidisciplinary antibiotic stewardship program that defines optimal antibiotic use and provides guidance for optimal antibiotic prescribed by physician/prescribers. The antibiotic stewardship program and its members will have accountability to the facility's quality assurance/performance improvement committee. The members of the antibiotic stewardship committee should include at a minimum the medical director of the facility, the director of nursing services, and the facilities consultant pharmacist. A. The medical director should set the standards for antibiotic prescribing. B. The director of nursing should establish the standards of nursing for assessment, resident…

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, record review, and interview, the facility failed to ensure a safe discharge, as evidenced by failing to provide necessary medications and reconciliation of all pre-discharge medications with the resident's post-discharge medications, upon discharge for 1 of 1 sampled resident reviewed for discharge (Resident #396). The findings included: The policy titled transfer, and discharge, dated 08/2023, indicated the transfer, and discharge process is designed to provide a safe, orderly transfer, or discharge from the center. The discharge planning process: the center will develop and implement discharge planning process that focuses on the resident's discharge goals and preparing residents to be active partners in post-discharge care, effective transition of the resident from SNF to post-SNF care, and the reduction of factors leading to preventable readmissions. The interdisciplinary team will involve the resident and resident representative in the development of the discharge plan, 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 observation, record review, and interview, the facility failed to develop a comprehensive care plan related to activities for 1 of 1 sampled resident who was dependent on the staff for access to activities (Resident #1). The findings included: During observations on 09/11/23 at 12:24 PM, 09/11/23 at 4:21 PM, 09/12/23 at 2:40 PM, 09/13/23 at 12:05 PM, 09/13/23 at 3:12 PM, and 09/14/23 at 1:39 PM, Resident #1 was observed not participating in any type of activity. Review of the record revealed Resident #1 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment, dated 08/25/23, documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5, on a 0 to 15 scale, indicating he was cognitively impaired. The MDS documented Resident #1 needed extensive to total assistance from staff for all Activities of Daily Living (ADLs), except eating. This MDS also documented that staff assessed Resident #1's preferences for activities that included music, pets,…

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 policy review, the facility failed to ensure proper care and services to prevent infection or other complications for 2 of 2 sampled residents with indwelling urinary catheters. Staff failed to provide proper perineal and catheter care, ensure proper anchoring of the catheter tubing, ensure a complete written order, and follow Enhanced Barrier Precautions (EBP) for Resident #4. The record lacked an appropriate order for the indwelling urinary catheter for Resident #40. The findings included: Review of the policy titled, Indwelling Catheter Care revised [DATE] documented, Maintenance: . Keep the drainage tube and collection bag lower that bladder. This policy further explained the need for two separate basins of water, one for catheter care and one for perineal care, cleansing the tubing away from the insertion site, avoid pulling on the catheter while cleaning it, and to provide slack while securing the catheter to the resident's thigh. As per Centers for…

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 collect a physician ordered stool sample for 1 of 1 sampled resident, who was having active diarrhea during her facility stay (Resident #79). The findings included: Review of the record revealed Resident #79 was admitted to the facility on [DATE], and passed away on 07/18/23. Review of the physician orders revealed an order dated 06/29/23 for staff to collect a stool sample for possible C-diff (clostridioides difficile, a bacterial infection of the colon). Further review of the record lacked any documentation of the attempt or inability to collect the stool sample, or any laboratory results for the test. Review of the Certified Nursing Assistant (CNA) documentation for bowel movement results between 06/29/23 and 07/18/23 revealed four documented medium sized watery and loose (liquid form) stools and 13 large watery and loose (liquid form) stools. During an interview on 09/14/23 at 11:38 AM, the South Unit Manager stated she did not recall, but believed…

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.