Nursing & Rehabilitation Center Of Melbourne

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify and provide ongoing monitoring of identified past trauma for 2 of 2 residents reviewed for Trauma Informed Care, of a total sample of 55 residents, (#25, #84).Findings: 1. Review of the medical record revealed resident #84, a [AGE] year-old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included: Alcohol Abuse, Adult Failure to Thrive, Moderate Dementia with Anxiety, Other Psychoactive Substance Abuse, Anxiety Disorder, Convulsions, Weakness, and Post Traumatic Stress Disorder (PTSD). The most recent Comprehensive Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/16/25 noted during the look-back periods, resident #84 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated moderate cognitive impairment. Cognitive Patterns were assessed with continuous/non-fluctuating behaviors of inattention and disorganized thinking. 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 follow their grievance process related to preferences for 2 of 2 resident reviewed for grievances, (#1, #3). Findings 1.A review of the medical record revealed that resident # 3 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, major depressive disorder, unspecified psychosis and schizoaffective disorder. According to the Annual assessment of the Minimum Data Set with the assessment reference date of 9/30/25, the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which means he was cognitively intact, and was dependent on staff for hygiene care. On 10/8/25 at 10:06 AM, resident # 3 who was selected from the facility's grievance log was observed being wheeled into the shower room. At 10:50 AM, resident #3 was observed coming out of shower room and answered only yes to everything is okay, staff treated him well him well and could not remember filing a grievance. On 10/8/25 at 1:47 PM the Social…

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 maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to appropriately implement enhanced barrier precautions (EBP) during high-contact care activity for 1 of 6 residents (#5) requiring EBP on the Specialized Subacute Unit (SSU). The facility had a total of 20 residents who required EBP in a census of 154 residents. The facility capacity is 167 beds.On 10/08/25 at approximately 10:50 AM the light above the door to resident #5's was illuminated to indicate the resident was calling for assistance. Certified nursing assistant (CNA)- A was observed to obtain and don a mask from a caddy (container) hanging on the door across the hallway and she entered the room. She was overheard to say to the resident, I will be right back to help you get dressed. The resident was in a private room.A sign on the door to resident #5's room read STOP. ENHANCED…

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 respond to grievances identified by resident council. Findings: During Resident Council meeting on 11/01/23 at 3:30 PM, members of Resident Council verified they met monthly. The members stated several grievances had been voiced regarding laundry, linen, nurse staffing, staff speaking other languages and dietary. The residents in attendance agreed the same concerns were voiced month after month without a resolution. The group expressed no one ever responded to the grievances and informed them of what was done. The resident council members were not aware of any grievances that had been filed on behalf of Resident Council. Review of Resident Council minutes from May 2023 through October 2023 revealed several repeat grievances concerning staff not speaking English, staff on cell phones, quality of linen and various dietary concerns. On 11/01/23 at 5:00 PM, the Activity Director stated she attended every Resident Council meeting along with her assistant. She explained the Resident Council agreed to have an open invitation to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the appropriate notices of financial liability for 2 of 3 resident reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, out of a total sample of 63 residents, (#53 and #96). Findings: 1. Resident #53 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including anemia, gastrointestinal hemorrhage, unspecified mood affective disorder and personal history of transient ischemic attack. Review of resident #53's financial record revealed she began Medicare Part A skilled nursing stay on 4/01/23 with last covered day on 4/28/23. She had Medicaid as her primary payer effective 4/29/23. A SNF Beneficiary Protection Notification Review revealed resident #53 received a Notice of Medicare Non-Coverage (NOMNC) at the end of her Medicare Part A stay but did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). 2. Resident #96 was admitted to the facility on [DATE]…

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 notify the State Long Term Care Ombudsman in writing, by phone, or in person for a facility-initiated emergency transfer/discharge for 2 of 2 residents reviewed for [NAME] Act and 1 of 3 residents reviewed for hospitalization out of a total sample of 63 residents, (#561, #562 and #626). Findings: 1. Review of the medical record revealed resident #561 was admitted to the facility on [DATE] and re-admitted on [DATE] from the hospital. His diagnosis included type II Diabetes, hypertensive heart disease with heart failure, mood disorders, history of traumatic brain injury, suicidal ideation, and anxiety disorder. The Minimum Data Set (MDS) Discharge-Return Anticipated assessment with assessment reference date of 3/16/22 revealed resident #561 had severely impaired cognitive skills for daily decision making. Review of the resident's medical record revealed the physician's progress note dated 3/16/22 indicated the resident was emergently transferred to 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 revise care plans to reflect current transfer status for 1 of 4 residents reviewed for accidents, (#1); accurate oxygen administration orders for 2 of 4 residents reviewed for respiratory care, (#56 and #57); failed to provide the opportunity to participate in review and revision of the plan of care for 1 of 2 residents reviewed for Care Planning, (#154); and failed to updated code status for 1 of 5 residents reviewed for Advance Directives, (#148), out of a total sample of 63 residents. Findings: Review of the facility's policy and procedure for Comprehensive Resident Centered Care Plans revealed the intent .to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. The document indicated the purpose to ensure residents received individualized, goal-directed care based on their needs through appropriate interventions, and provide 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 observation, interview and record review, the facility failed to ensure dishes were rinsed at the appropriate temperature and with the proper level of sanitizer with regard to the dish machine's data plate and manufacturer's instructions and failed to maintain equipment in a safe condition. Finding: On 10/30/23 at 10:25 AM, during kitchen observation, staff were observed running dishes through the dish machine. The temperature dial on the dish machine did not register the rinse temperature. The Data Plate on the machine noted the rinse temperature should be 120 degrees Fahrenheit (F). The Certified Dietary Manager (CDM) acknowledged the gauge was not registering the water temperature on the rinse cycle. She explained the dish machine was a low-temp chemical machine. Dietary Aide K was observed as she removed wet plates from the dishwasher, stacked them and placed them in the plate warmer with other plates. The CDM asked Dietary Aide K to test the chemical parts per million (ppm). Dietary aide K removed a container of test strips from the top of the dish machine, opened 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 ensure the Quality Assurance and Performance Improvement (QAPI) program developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to respiratory care. Findings: Cross reference F641, F657, and F695 Review of the facility's survey history revealed repeat deficiencies related to accuracy of Minimum Data Set (MDS) assessments, timing and revision of care plans and failure to ensure oxygen delivery per physician order during the current survey ending on 11/02/23. Past deficiencies revealed systemic concerns with similar findings on the previous recertification survey dated 2/03/22 for accuracy of MDS assessments and revision of care plans and on the past two previous recertification surveys (2/03/22 and 10/20) for oxygen delivery per physician orders. In an interview on 11/02/23 at 4:48 PM, the Administrator was unable to say what changes were made after the last survey to ensure the same concerns with MDS assessments, care plans and oxygen delivery did not reoccur. She…

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 adhere to proper infection control practices for cleaning of a glucometer to prevent the potential transmission of bloodborne pathogens for 1 of 2 residents tested for blood glucose levels, (#75), out of a total sample of 63 residents; and failed to ensure staff used proper hand hygiene during meal service with the potential to spread infection to residents on the [NAME] Wing. Findings: 1. Review of the medical record revealed resident #75 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and end stage renal disease with dependence on hemodialysis. Review of the Medication Administration Record revealed resident #75 had a physician order dated 10/14/23 for Novolog Flexpen ReliOn Subcutaneous Solution Pen-injector 100 units per milliliter to be injected according to a sliding scale, two times daily. Resident #75 had a care plan for Diabetes, initiated on 5/20/22, which directed nurses to obtain blood glucose…

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 the right to make choices about significant aspects of activities of daily living related to the preferred method and frequency of baths for 2 of 5 residents reviewed for choices, out of a total sample of 63 residents, (#624 & #617). Findings: 1. Review of the medical record revealed resident #624 was admitted to the facility on [DATE] with diagnoses including heart disease, left leg below-knee amputation, generalized muscle weakness, and need for assistance with personal care. The Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 10/22/23 revealed resident #624 had clear speech, was able to express his ideas and wants, and understood others. The document showed the resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated he was cognitively intact. Section F of the MDS assessment, Preferences for Customary Routine and Activities, revealed resident #624 felt it 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents wishes for a Do Not Resuscitate Order (DNRO) were honored for 1 of 2 residents, (#6), and failed to ensure residents had the capacity to make health decisions and sign for a DNRO for 1 of 2 residents reviewed for Advanced Directives, from a total sample of 63 residents, (#107). Findings: 1. Review of the medical record revealed resident #6 was admitted from an acute care hospital on [DATE] with diagnoses of stroke, atherosclerosis (arterial narrowing and clotting) of the heart and both legs, heart rhythm malfunction, presence of a cardiac pacemaker, and paranoid schizophrenia. The Minimum Data Set (MDS) Annual Assessment with Assessment Reference Date (ARD) of [DATE] noted the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact. The assessment showed she had disorganized thinking that fluctuated in severity, and had not rejected evaluation or care. The Comprehensive…

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 Minimum Data Set (MDS) assessments accurately reflected transfer status, (#1), and vision status, (#15), at the time of the assessments, for 2 of 63 sampled residents. Findings: 1. Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, heart disease, anxiety and depression. Review of the MDS Quarterly assessment with assessment reference date (ARD) of 8/24/23 indicated resident #1 required extensive assistance from two or more staff for transfers between surfaces including to or from the bed and wheelchair. On 10/31/23 at 10:10 AM, Certified Nursing Assistants (CNAs) Q and R transferred resident #1 from her bed to a reclining wheelchair with a mechanical lift. CNA R explained the resident required a mechanical lift for all transfers as she could not stand, follow directions, or assist staff. On 11/01/23 at 11:47 AM, CNA P stated she was regularly…

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 refer residents with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 2 of 6 residents reviewed for PASARR, out of a total sample of 63 residents, (#37 and #83). Findings: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, heart failure and unspecified dementia. Review of the Minimum Data Set (MDS) annual assessment with assessment reference date (ARD) of 10/09/23 revealed resident #37 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. The document indicated her active diagnoses included depression (other than bipolar), psychotic disorder (other than schizophrenia) and unspecified mood [affective] disorder. Review of resident #37's electronic medical record (EMR) revealed diagnoses of major depressive disorder with an onset date of 7/18/17, unspecified psychosis with an onset…

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 follow policies and procedures and adhere to professional standards related to wound care and treatment for 1 of 5 residents reviewed for non-pressure skin conditions, out of a total sample of 63 residents, (#47). Findings: Review of the medical record revealed resident #47 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, generalized muscle weakness, lack of coordination, muscle wasting and atrophy of the lower legs, and difficulty walking. Review of the Minimum Data Set (MDS) Medicare Part A Stay assessment with assessment reference date of 10/06/23 revealed resident #47 had a Brief Interview for Mental Status score of 12 which indicated moderate cognitive impairment. The document showed he had skin tears and nonsurgical dressings. Review of the medical record revealed resident #47 had a care plan for fall-related skin tears to his right and left arms, initiated on 10/12/23. The goals noted 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 arrange services in a timely manner to ensure access to appropriate prescription glasses, (#15); and failed to provide glasses to maintain vision abilities, (#154), for 2 of 6 residents reviewed for Vision/Hearing out of a total sample of 63 residents. Findings: 1. Review of the medical record revealed resident #15 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, seizures, chronic pain, insomnia, and need for assistance with personal care. Resident #15 had a care plan for glasses to correct visual impairment initiated on 8/31/22 and revised on 7/05/23. The goal noted the resident would not experience a decline in visual function or have indicators of acute eye problems. The interventions included arrange consultation with an eye practitioner as required, monitor and report symptoms of acute eye problems, and remind the resident to wear her glasses when up. On 10/31/23 at 9:50 AM, resident #15 explained…

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 oxygen therapy was administered according to physician orders for 2 of 4 residents reviewed for respiratory care, out of a total sample of 63 residents, (#56 and #57). Findings: 1. Review of the medical record revealed resident #57 was admitted to the facility on [DATE] with diagnoses including shortness of breath, dementia, and cognitive communication deficit. The Minimum Data Set (MDS) Significant Change in Status assessment with assessment reference date (ARD) of 8/24/23 revealed resident #57 used oxygen. The resident had a care plan for oxygen therapy related to shortness of breath initiated on 6/16/23. The interventions included oxygen setting of 2 liters per minute (L/min) continuously via nasal cannula. Review of the medical record revealed resident #57 had a physician order dated 8/03/23 for oxygen at 2 L/min as needed that was discontinued on 10/26/23. On 10/30/23 at 12:08 PM, resident #57 wore his nasal cannula with one…

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 maintain safe and secure storage of medication to prevent access by unauthorized persons for 1 of 2 medication carts on the East Wing (400 hall). Findings: On 10/30/23 at 5:47 PM, Registered Nurse (RN) G stood at his cart and prepared medications for administration. He removed one pill from a blister pack and placed it in a small plastic cup. RN G recalled he had not yet checked the resident's blood pressure and pulse, so he placed the cup in top drawer of the medication cart and entered room [ROOM NUMBER]. The medication cart was located against the wall, across and down the hallway from room [ROOM NUMBER]. RN G did not lock the medication cart and on inspection, all drawers opened freely and medications were easily accessible. While RN G was in room [ROOM NUMBER], a resident exited the room next to the medication cart and propelled his wheelchair in close proximity to the open drawers. When RN G exited room [ROOM NUMBER], he…

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 follow up dental services for 1 of 2 residents reviewed for Dental out of a total sample of 63 residents, (#154). Finding: Review of the medical record revealed resident #154 was admitted to the facility on [DATE] from an Assisted Living Facility, with diagnoses of abdominal wall abscess (infection), stroke, mood disorder, anxiety, and dementia. The most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date of 8/23/23 noted the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated the resident was not cognitively impaired. The assessment showed the resident required staff support and assistance to complete Activities of Daily Living (ADLs). On 10/31/23 at 11:38 AM, resident #154 was visibly distressed when he explained he had been waiting for follow up dental services for months since he was seen by the facility's Dentist. He said the provider recommended partial…

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 required built up utensils and weighted cup were provided for 1 of 5 residents reviewed for nutrition of a total sample of 63 residents, (#41). Findings: Resident #41 was admitted to the facility on [DATE] with diagnoses that included stroke, difficulty swallowing after stroke, chronic lung disease, protein-calorie malnutrition, muscle wasting and weakness. Review of the Minimum Data Set assessment dated [DATE] revealed resident #41 was cognitively intact but required one-person physical assist for eating supervision. Review of the Order Summary Report dated 11/02/23 revealed resident #41 had a physician's order for a regular diet with regular texture and nectar thickened fluids. The order report also showed an Occupational Therapy (OT) clarification order for resident #41 to have a blue 8 ounce (oz.) weighted cup with blue lid and built-up utensils with all meals dated 7/27/23. Resident #41 had a care plan for increased…

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 maintain smoking pole ashtrays to promote a safe environment in the designated smoking area; and failed to ensure hot water was available in two of three shower stalls in the [NAME] Wing shower room. Findings: 1. On 1/31/22 at 1:13 PM, during a tour of the facility's designated smoking area, a moderate amount of smoke was noted coming from the holes at the top of a smoking pole ashtray. The Activities Coordinator was alerted to the smoke by a resident who stood nearby. He quickly walked towards the ashtray, removed the top half of the unit, and used a nearby green plastic watering can to put out smoldering cigarette butts in the base of the container. The Activities Coordinator validated the base of the ashtray contained a thick layer of cigarette butts over two inches deep. Inspection of the two additional smoking poll ashtrays in the smoking area revealed they contained a thick layer of butts, also over two inches deep. He acknowledged ashtrays left in this condition could be fire hazards. He stated either…

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 Minimum Data Set (MDS) assessments accurately reflected Range of Motion (ROM) for 2 of 2 residents reviewed for ROM (#258, #27) failed to accurately assess bowel continence for 1 of 1 resident (#61), failed to identify discharge status for 1 of 1 resident reviewed for discharge, (#1), failed to accurately assess dental status for 2 of 3 residents reviewed for dental, (#32, #27) and failed to accurately assess active diagnoses for 1 of 5 residents, (#27) out of a total sample of 65 residents. Findings: 1. Resident #258 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, heart failure, acute embolism and thrombosis, and hemiplegia and hemiparesis affecting left non dominant side. Review of the Hospital Discharge Summary revealed the resident had chronic contracture left upper and lower extremity consistent with previous CVA (Cerebrovascular Accident), left sided weakness. The resident's admission MDS…

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 care and services for splinting to prevent worsening of contractures for 4 of 5 residents reviewed for mobility of a total sample of 65 residents, (#27, #46, #74, and #137). Findings: 1. Resident #27 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, stroke with left side weakness and paralysis affecting left dominant side, and nerve damage to hands and feet. The Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of [DATE] revealed resident #27 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. The assessment showed the resident did not reject evaluation or care that was necessary or his health and well-being. The MDS assessment did not include the resident's active diagnoses and it did not reflect his functional limitation in Range of Motion (ROM). The documents indicated resident #27 did not received therapy 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 interview and record review, the facility failed to complete a Level II Preadmission Screening and Resident Review (PASARR) to ensure appropriate placement and evaluation for specialized services for 1 of 1 resident reviewed for Level II PASARR, of a total sample of 65 residents, (#62). Findings: Resident #62 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. His diagnoses included End-Stage Renal Disease, chronic atrial fibrillation, major depressive disorder, heart failure, schizoaffective disorder, and hepatic failure. Review of the resident's Level I PASARR dated 9/17/21 revealed Section IV: PASARR Screen Completion read, Individual may not be admitted to a Nursing Facility. Use this form and required documentation to request a Level II PASARR evaluation because there is a diagnosis of or suspicion of indicated a Dx [diagnosis] of/or suspicion of . Serious Mental Illness. Guidance included in Appendix PP of the State Operations Manual read, The resident's Level…

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 develop and implement a baseline care plan to address necessary care and services for tracheostomy, oxygen, suctioning, feeding tube, activities of daily living, and pain management for 1 of 9 newly admitted residents, (#111); and failed to ensure the baseline care plan summaries were reviewed with the resident or resident representative within 48 hours for 3 of 9 newly admitted residents, (#111, #303, #258), out of a total sample of 65 residents. Findings: 1. Resident #111 was admitted to the facility on [DATE]. His diagnoses included chronic respiratory failure with hypoxia, convulsions, tracheostomy status and gastrostomy status. Review of the medical record revealed an Admission/readmission Data Collection form dated 1/11/22 at 9:39 PM, which showed special treatments and procedures for oxygen, tracheostomy, seizures, and percutaneous endoscopic gastrostomy (PEG) tube. On 2/03/22 at 5:45 PM, review of resident #111's medical record with Registered…

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 develop comprehensive care plans related to oxygen use for 1 of 4 residents reviewed for respiratory care, (#138). Findings: 1. Resident #138 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure and atrial fibrillation. Review of resident #138's Minimum Data Set (MDS) admission assessment dated [DATE], Section O, revealed she was received oxygen while a resident and prior to admission to the facility. Section J of the MDS assessment indicated resident #138 suffered from shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat. Review of the medical record revealed a physician's order dated 12/17/21 that read, oxygen as needed PRN 2 liters via [nasal] cannula. The order was discontinued and a new order dated 2/01/22 read, Oxygen as Needed PRN (as needed) 4 liters/via [nasal] cannula. Review of resident #138's medical record revealed…

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 develop comprehensive care plans within 7 days of completion of the comprehensive Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for catheter (#61) and for 1 of 5 residents reviewed for participation in care planning (#149), of a total sample of 65 residents. Findings: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses of diabetes type II, intervertebral disc degeneration lumbar region, anxiety disorder, cardiac pacemaker, benign prostatic hyperplasia, and obstructive and reflux uropathy. Review of the resident's medical record revealed physician's orders dated 11/29/21 for a urinary catheter size 16, change catheter as needed, and catheter care every shift as needed. Review of the resident's admission MDS assessment with Assessment Reference date (ARD) of 12/04/21, revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 14/15. Section H of the MDS assessment revealed 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 schedule follow-up care with an orthopedic physician in a timely manner for 1 of 1 resident with a right wrist /hand fracture and right-hand cast, of a total sample of 65 residents, (#58). Findings: Resident #58 was admitted on [DATE] with diagnoses of Corona Virus 2019 disease, wedge compression fracture 5th lumbar vertebra, fracture of the right wrist and hand, generalized muscle weakness, and fall. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 11/20/21 revealed the resident's diagnoses included right radius fracture, and she had a closed reduction the right radius surgical procedure performed. Discharge instructions from the hospital dated 11/25/2021 read, To make appt [appointment] for MD [Medical Doctor], GI [Gastroenterologist], Oncology, Pulmonology. An undated, handwritten note read, Patient needs a follow-up ortho appointment for cast and screws in the right arm 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, interview, and record review, the facility failed to provide dressing changes for seven days for a midline intravenous (IV) catheter according to current professional standards of practice for 1 of 2 residents with IV catheters of a total sample of 65 residents, (#260). Findings: Resident # 260 was admitted to the facility on [DATE] with diagnoses including sickle cell disease, convulsions, and respiratory failure. An admission / readmission Data Collection form dated 1/28/22 indicated the resident was alert and oriented to person, place, and time, and had no vascular access IV present. On 2/02/22 at 11:30 AM, resident #260 had a midline IV catheter noted in his right upper arm with a dressing dated 1/25/22. The transparent dressing that measured approximately 4 centimeters (cm) x 5 cm and covered the midline IV insertion site. The edges of the dressing were noted to be loose and not secured to the skin. Resident #260 said, I came from the hospital with this midline dressing. I told 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 ensure oxygen (O2) therapy was administered as per physician's orders for 1 of 3 residents reviewed for O2, of a total sample of 65 residents, (#62). Findings: Resident #62 was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included End Stage Renal disease, chronic atrial fibrillation, major depressive disorder, heart failure, schizoaffective disorder, and hepatic failure. Review of the medical record revealed a physician's order dated 1/31/22 for Oxygen 3 liters per minute (L/min) continuously every shift for shortness of breath (SOB). A progress note dated 2/01/22 at 5:52 PM indicated resident #62 had labored breathing SOB on exertion SOB lying flat . Oxygen is used via nasal cannula 3 L/min . On 2/01/22 at 9:46 AM, resident #62 was observed with O2 infusing via nasal cannula at 4.5 L/min. The resident stated he was not sure of the correct setting for his oxygen. On 2/01/22 at 9:52 AM, Registered…

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 10 of 12 required monthly drug regimen reviews were completed for 1 of 5 residents reviewed for Unnecessary Medications, Psychotropic Medications and Medication Regimen Review, out of a total sample of 65 residents, (#2). Findings: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including depressive disorder, hypertension, long term use of insulin, type 2 diabetes and left hip pain. Review of the medical record revealed resident #2 had physician orders for Duloxetine 60 milligrams (mg) daily for depression, Hydroxyzine 25 mg three times daily for anxiety, Aspartame insulin 100 units/ml (milliliter) inject four units three times a day for diabetes, Detemir Solution insulin 100 units/ml inject 20 units at bedtime for Diabetes, Spironolactone 25 mg give once daily for diuresis, Trulicity Solution Pen-Injector 0.75 mg/0.5ml inject 1 dose every Saturday morning for diabetes, Hydrocodone-Acetaminophen 5-325…

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.