Rehabilitation Center Of Orlando

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure residents were treated with dignity by standing while assisting them to eat for 1 out of the 5 residents observed for dining assistance, of a total sample of 38 residents, (#34).Findings:Resident #34 was admitted the facility on 7/10/17 for Parkinson's disease, diabetes mellitus type II, seizures, depression, anxiety, and psychotic disorder. Resident #34's care plan indicated he had a deficit in activities of daily living (ADL's) and required maximum to total assistance for eating meals related to risk for nutritional decline and history of weight loss with a low Body Mass index. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident #34's Brief Interview for Mental Status score was 6/15, which indicated severe cognitive impairment.On 7/23/25 at 12:13 PM, Certified Nursing Assistant (CNA) F was observed standing in the main dining room as she assisted resident #34 with lunch. At 12:19 PM, CNA F explained 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 interview, and record review, the facility failed to conduct a thorough investigation for an injury of unknown origin for one of one resident reviewed for falls, of a total sample of 38 residents, (#3).Findings:Resident #3 was admitted to the facility on [DATE] for atrial fibrillation, dementia, muscle wasting and atrophy, disorders of bone density and structure, and repeated falls added on 6/02/25. She had an order for an anticoagulant medication due to her atrial fibrillation. On her most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], her Brief Interview for Mental Status score was determined to be 14 of 15, which indicated an intact cognitive status.Resident #3 had a care plan with a focus area dated 6/03/25 which described the resident had a fall. The care plan intervention was to determine and address causative factors of the fall, which did not happen.On 7/22/25 at 10:02 AM, resident #3 said about two months ago an aide was pushing her too fast in the wheelchair and she fell…

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 act promptly upon Resident Council group concerns with appropriate responses and rationale for facility decisions. Findings: On 8/07/24 at 3:18 PM, the Resident Council President stated there were issues brought up in resident council meetings for many months that were still unresolved. The first issue was a long response time to call lights by staff. He stated staff often told the residents; they would be right back but then forgot to return. He added staff would say, That's not my section, when asked to answer a call light or pass meal trays when the assigned Certified Nursing Assistant (CNA) was busy. The Resident Council President explained there were other ongoing issues such as late meals, cold food due to the plate warmer being broken for months, and residents not being able to get ice. He explained the Resident Council had concerns about language barrier issues with staff, and smoking issues. The Resident Council President stated the group was concerned the Activities Director had at times invited staff 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.

Based on interview and record review, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained. Findings: Cross reference F565 and F609 Review of the facility's survey history revealed deficiencies related to Resident Council's grievances and recommendations to improve residents' care had not been considered or acted upon and an allegation of abuse was not reported were identified during the current survey ending on 8/08/24. The facility had deficiencies at F565 and F609 for similar concerns with Resident Council and reporting of abuse allegations from the last Recertification survey dated 1/11/24. Review of the Plan of Correction (POC) which serves as the facility's allegation of compliance with the citations, approved by the Quality Assurance and Performance Improvement (QAPI) committee on 2/15/24 included education to the Interdisciplinary team for understanding of the QAPI process. The POC…

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 report an allegation of verbal abuse to State agencies as required for 1 of 2 residents reviewed for abuse, of a total sample of 8 residents, (#1). Findings: Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses including encephalopathy (brain dysfunction), paraplegia (paralysis of lower body) and dementia. Her medical record showed her daughter was her Power of Attorney (POA) and responsible party. Resident #1 was discharged from the facility on 6/30/24. Review of the Minimum Data Set (MDS) Annual assessment with assessment reference date of 5/27/24 revealed resident #1 had unclear speech but sometimes understood and responded adequately to simple, direct communication only. The assessment showed a Brief Interview for Mental Status (BIMS) was not conducted because she was rarely or never understood. The MDS assessment showed resident #1 had no behavioral symptoms and did not reject evaluation or care…

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, pressure ulcer care, nurse staffing postings and kitchen sanitation. Findings: Cross reference F686, F695, F732 and F812 Review of the facility's survey history revealed repeat deficiencies related to the delivery of oxygen per physician orders, provision of preventive care for pressure ulcers, retaining and posting of daily nurse staffing sheets and the cleanliness and sanitation of the kitchen during the current survey ending 1/11/24. Past deficiencies revealed systemic concerns with comparable findings on the previous recertification survey of 5/31/22 for pressure ulcer care and prevention, posting and retaining of daily nurse staffing forms, and following physician orders for oxygen delivery. As well as a repeat deficiency for sanitation of food surfaces in the kitchen from a recent complaint survey on 12/14/23. Review…

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 group interview and record review, the facility failed to ensure group grievances were acted upon promptly and provide a response and/or possible solution to group concerns for 6 months reviewed. Findings: During the Resident Council meeting held on 01/08/24 at 2:04 PM, members of Resident Council confirmed they met monthly. The members in attendance stated they were frustrated and upset about grievances that had not been resolved regarding dietary, staffing, and staff speaking other languages. All residents in attendance agreed they had the same concerns and their grievances had not been addressed. The residents stated the eggs served to them were uncooked and were not real eggs; eggs were cold, liquid and runny; portion size was small; the meals did not match the meal ticket; hot food was served cold; and food trays did not close properly for food to stay hot. They noted it took 10 to 15 minutes after the food carts arrived on the unit for the staff to pass out the meal trays. They explained there was no team work with the staff. If Certified Nursing Assistants (CNAs)…

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. Resident #46 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. His diagnoses included fractured femur, orthopedic aftercare, and anemia. Review of resident #46's medical record revealed a nursing progress note dated 12/13/23 that noted he was hospitalized for a change of condition, Pain [uncontrolled] and the primary provider instructed to send to the hospital. The facility Transfer to Hospital form dated 12/13/23 indicated unplanned transfer due to recent fall on 12/8/23. Review of the hospital record dated 12/13/23 revealed his principal problem was fractured femur due to fall 5 days ago at SNF (Skilled Nurse Facility). The medical record did not contain Nursing Home Transfer and Discharge Notice form for this hospitalization. On 1/11/24 at 1:40 PM, the facility Nursing Home Administrator stated he was not aware who was responsible for completing the Nursing Home Transfer and Discharge Notice form and notification to the Ombudsman when a resident was transferred 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 observation, interview, and record review, the facility failed to provide appropriate care and services for splinting to prevent worsening of contractures for 1 of 1 residents reviewed for limited range of motion, out of a total sample of 57 residents, (#44). Findings: Review of the medical record revealed resident #44 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including encephalopathy (brain dysfunction), paraplegia, stroke, and contractures of all extremities. A contracture is limited movement of a join caused by shortening or contracting of muscles in the arms or legs due to inactivity or inability to move. Contractures are prevented and treated by regular movement and range of motion or stretching exercises, and use of splints to maintain a contracture in a stretched position (retrieved on 1/17/24 from www.drugs.com/cg/contracture-ambulatory-care.html). The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 11/28/23 revealed 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 observation, interview, and record review, the facility failed to provide sufficient licensed nurses on the 7:00 AM to 7:00 PM shift to meet the needs and achieve the goals according to the plans of care for residents on 2 of 2 units, (West and East Wings). Findings: 1. On 1/07/24 at 11:43 AM, Licensed Practical Nurse (LPN) E stood at his medication cart in the hallway outside room [ROOM NUMBER]. The computer screen displayed medication administration tasks in red and LPN E explained the red color indicated the residents' medications were late. He confirmed most of the medications were scheduled for 9:00 AM and should have been given by 10:00 AM at the latest. He stated he was scheduled to work from 7:00 AM to 7:00 PM but came in late for his shift this morning. LPN E explained he was scheduled to work from 7:00 AM to 7:00 PM yesterday, but ended up working until almost 1:00 AM as no nurse showed up to take his assignment. He stated the facility was eventually able to find a nurse from a staffing agency…

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 pharmaceutical services to ensure timely medication administration in accordance with accepted standards of practice for 1 of 5 residents reviewed for unnecessary medications, (#25); and failed to acquire medications within an appropriate timeframe for 1 of 19 residents with new admission status, (#218), out of a total sample of 57 residents. Findings: 1. Review of the medical record revealed resident #25 was admitted to the facility on [DATE] with diagnoses including epilepsy, major depressive disorder, anxiety disorder, communication/comprehension disorder, tremors, migraine headaches, and insomnia. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 11/14/23 revealed resident #25 had a Brief Interview for Mental Status score of 5 which indicated she had severe cognitive impairment. The MDS assessment showed the resident had no behavioral symptoms and did not reject evaluation or care that 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 observation, record review, and interview, the facility failed to ensure the menus/recipes were being followed and failed to demonstrate that a reasonable effort was made to ensure the menu/food met the needs of the residents. The facility also failed to ensure residents received foods based on the menus and meal tray tickets for 1 of 3 sampled residents, #53, in a total sample of 57 residents. Findings: 1. On 1/8/24 at 2:04 PM, a meeting was held with the resident council group. They conveyed their displeasure with the menus and foods they were served. They expressed concerns that some of the meals were not palatable and food portions were small. One resident stated he was to receive double portions according to his meal tray ticket, but at times he did not receive double portions when the meal tray arrived at his room. The residents all agreed the food items they received did not match the meal tray ticket which identified their nutritional needs and food preferences. Several of the residents reported…

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, record review, and group interview, the facility failed to ensure meals were palatable, attractive, and served at an appetizing temperature. Findings: Cross reference: F803 During the group interview conducted 01/08/24 at 2:04 PM, 16 interviewable residents complained the food was not served hot, was not palatable, and was not nutritious. The residents stated the eggs served to them were uncooked and were not real eggs; eggs were cold, portion size was small; the meals did not match the meal ticket; hot food was served cold; there was no fresh fruits or vegetables, only frozen or canned. Review of the lunch menu for 1/10/24 revealed the main entree consisted of Classic Meatloaf, Cheesy Mashed Potatoes, Harvard Beets and Cinnamon Baked Apples. On 1/10/2024 at 12:00 PM, a lunch test tray was requested. At 12:35 PM, the last food tray was served to a resident. At 12:40 PM, the food tray was sampled. Meat loaf registered 118 degrees Fahrenheit and had no taste and did not appear to contain onions or green peppers. Mashed potatoes registered 138 degrees Fahrenheit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain medical records that accurately documented completion of physician-ordered wound treatments for 1 of 7 residents reviewed for pressure ulcers, (#44); oxygen administration for 2 of 2 residents reviewed for respiratory care, (#57 & #28); and provision of activities of daily living (ADL) care for 1 of 7 residents reviewed for ADLs, (#40), for 4 out of a total sample of 57 residents. Findings: 1. Review of the medical record revealed resident #44 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including encephalopathy (brain dysfunction), paraplegia, dementia, comprehension/communication disorder, stroke, contractures of all extremities, and pressure ulcers of the left hip and sacrum. Review of the Order Listing Report revealed resident #44 had physician orders dated 12/22/23 for wound treatments to her sacrum and right hip. The orders instructed nurses to cleanse the areas with wound cleanser, pat…

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' right to privacy during intimate encounters for 2 of 2 residents reviewed for privacy, out of a total sample of 57 residents, (#48 and #35). Findings: 1. Resident #48 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, paraplegia, , major depressive disorder and generalized anxiety. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date of 11/15/23 revealed resident #48 had a Brief Interview for Mental Status score of 15 out of 15 which indicated he was cognitively intact. The document indicated he was able to make himself understood and understood others and did not exhibit any aggressive behaviors. On 1/08/24 at 12:35 PM, resident #48 stated he had a girlfriend who was another resident at the facility. He explained they had been dating for about a year but began getting physical about a month ago and had intimate encounters in his room. Resident #48 stated 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, interview, and record review, the facility failed to provide documented evidence that grievances were resolved promptly, and residents/family members were apprised of progress toward a resolution of grievances for 2 of 2 residents reviewed for grievances out of a total sample of 57 residents, (#54, 34). Findings: 1. Resident #54 was admitted to the facility on [DATE] with diagnoses including Friedreich Ataxia, cardiomyopathy, dependence in wheelchair, lack of coordination and muscle weakness. Friedreich ataxia (FA) is a rare inherited disease that causes progressive damage to your nervous system and movement problems (retrieved on 1/12/24 from https://www.ninds.nih.gov/health). Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed resident #54's Brief Interview for Mental Status (BIMS) score was 15 of 15 which indicated he was cognitively intact. The MDS assessment showed the resident was moderately dependent on staff for his activities of daily living (ADL) such…

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 report an allegation of staff-to-resident abuse to State agencies within the required 2-hour timeframe, and failed to report the incident to law enforcement for 1 of 4 residents reviewed for abuse, out of a total sample of 57 residents, (#13). Findings: Review of the medical record revealed resident #13 was admitted to the facility on [DATE] with diagnoses including pain in her lower back and bilateral lower legs, blood clots in bilateral legs, opioid dependence, morbid obesity, muscle spasms, depression, and insomnia. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 12/05/23 revealed resident #13 had clear speech, was able to express ideas and wants, and had no comprehension issues. The resident's Brief Interview for Mental Status score was 15 which indicated she was cognitively intact. The MDS assessment showed resident #13 had no behavioral symptoms and did not reject evaluation or care necessary to achieve her goals…

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 oxygen therapy per physician orders for 2 of 2 residents reviewed for oxygen therapy of a total sample of 57 residents, (#28, and #57). Findings: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, hypertension, Type 2 Diabetes Mellitus, and shortness of breath. Resident #28's Quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact, required substantial assistance to roll in bed and did not get out of bed to walk nor use a wheelchair or scooter for mobility. The assessment also indicated resident #28 used oxygen. Resident #28 had a care plan for risk of respiratory distress related to shortness of breath and use of continuous oxygen dated 6/12/23. The goal was for resident #28 to maintain an optimal breathing pattern and to remain free of respiratory distress. The care plan interventions included administration of oxygen as ordered by the physician. Review of…

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 prevent medication administration error rate of 5% or greater for 1 of 4 residents sampled for medication administration, (#35). There were 2 medication errors in 26 opportunities for a medication error rate of 7.69%. Findings: Resident #35's medical record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included stroke, myocardial infarction, hypertension, congestive heart failure, mood disorder, anxiety, depression, and pseudobulbar affect. Pseudobulbar affect (PBA) is a condition that's characterized by episodes of sudden uncontrollable and inappropriate laughing or crying (retrieved on 1/12/24 from https://www.mayoclinic.org). On 1/8/24 at 9:25 AM, Registered Nurse (RN) B prepared to administer resident #35's 11 scheduled morning medications and placed a total of 10 ½ pills into a small plastic cup which included Aspirin 81 milligram (mg) enteric coated tablet and did not include…

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 accepted standards of practice to prevent cross-contamination during wound care for 1 of 2 residents observed during wound care, (#44) to control and prevent infections for 2 out of a total sample of 57 residents. Findings: Review of the medical record revealed resident #44 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including encephalopathy (brain dysfunction), paraplegia, dementia, comprehension/communication disorder, stroke, contractures of all extremities, and pressure ulcers of the left hip and sacrum. The National Pressure Injury Advisory Panel defines a pressure ulcer or pressure injury as localized damage to the skin and underlying soft tissue usually over a bony prominence.The injury can present as intact skin or an open ulcer and may be painful (retrieved on 1/14/24 from www.npiap.com). The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 11/28/23 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 conduct care plan meetings as scheduled, and failed to ensure the meetings were attended by the appropriate interdisciplinary team (IDT) members required to thoroughly review and/or revise the goals and care needs for 1 of 4 residents reviewed for care planning, out of a total sample of 57 residents, (#25). Findings: Review of the medical record revealed resident #25 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including generalized epilepsy, difficulty swallowing, depressive disorder, anxiety, depression, comprehension/communication disorder, and insomnia. The resident's demographic sheet indicated her father was the emergency contact, responsible party and healthcare proxy. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 11/14/23 revealed resident #25 had a Brief Interview for Mental Status score of 5, which indicated she had severe cognitive impairment. The document showed 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 perform physician-ordered wound treatments according to professional standards of practice to promote wound healing for 1 of 7 residents reviewed for pressure ulcers, out of a total sample of 57 residents, (#44). Findings: Review of the medical record revealed resident #44 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including encephalopathy (brain dysfunction), paraplegia, dementia, comprehension/communication disorder, stroke, contractures of all extremities, and pressure ulcers of the left hip and sacrum. The National Pressure Injury Advisory Panel defines a pressure ulcer or pressure injury as localized damage to the skin and underlying soft tissue usually over a bony prominence.The injury can present as intact skin or an open ulcer and may be painful (retrieved on 1/14/24 from www.npiap.com). The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 11/28/23 revealed 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.

Based on observation, interview, and review of facility documentation, the facility failed to ensure that surfaces of cooking equipment were kept free of accumulation of food residue as defined by facility policy concerning the cleaning of the oven. Findings: A tour of the kitchen was performed on 12/13/23 at 11:25 AM. Observation in the kitchen revealed the interior of the convection oven was covered with excessive amount of grease residue on interior walls, doors (with glass for viewing) and racks. During an interview, the Dietary Manager indicated the oven interior was cleaned once per week. He stated he did not have any logs which documented such cleanings. During a follow-up interview on 12/14/23 at approximately 10:45 AM, the Dietary Manager stated the weekly cleanings utilized grease stripping agent. He explained the oven interior surface was sprayed and allowed to sit and soak, then wiped down until fully cleaned. A review of the facility's policy on kitchen cleaning schedule read, Ovens will be cleaned as needed and according to the cleaning schedule (at least once every…

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 appropriate care and services for oxygen therapy for 1 of 3 residents reviewed for respiratory care, of a total sample of 44 residents, (#10). Findings: Resident #10 was admitted to the facility on [DATE] with diagnoses of heart disease, enlarged heart, hardening of the blood vessels in the brain, muscle weakness and chronic pain. Review of the Minimum Data Set (MDS) Quarterly assessment with Assessment Reference date 3/9/22 revealed resident #10 had severe hearing impairment and no speech. The MDS assessment indicated resident #10's cognition was severely impaired and had memory problems. The assessment showed she had a life expectancy of less than 6 months and required supplemental oxygen. The document revealed resident #10 required extensive assistance from staff for most of her care needs and she received Hospice care at the facility. A care plan initiated on 2/17/22 for risk for respiratory failure and requirement of oxygen…

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

Based on observation, and interview, the facility failed to post the daily nurse staffing for licensed and unlicensed nursing staff directly responsible for nursing care per shift. Findings: On 3/28/22 at 9:10 AM, the nurse staffing information form dated 3/18/22 was posted in the front lobby by the receptionist's window. On 3/28/22 at 5:50 PM, the nurse staffing information form was observed posted with the date 3/18/22 in the front lobby in the same place by the receptionist's window. On 3/29/22 at 9:30 AM, the nurse staffing information form posted in the front lobby next to the receptionist's window was still dated 3/18/22. On 3/29/22 at 1:04 PM, the nurse staffing information form dated 3/18/22 was removed, and no nurse staffing information form was posted. On 3/29/22 at 1:20 PM, the Staffing Coordinator stated she was responsible for completing the daily nurse staffing information form. She stated she removed the form earlier today to make corrections. She explained she was responsible to take down the old posting and put up the new one each day. The Staffing Coordinator…

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 the physician laboratory orders for 1 of 5 residents reviewed for unnecessary medications of 44 sampled residents, (#147). Findings: Resident #147 was admitted to the facility on [DATE] with diagnoses of dementia, repeated falls, urinary tract infection, delusional disorder, hypokalemia (low potassium level), protein calorie malnutrition and chronic kidney disease. A medical record review revealed a physician order dated 3/19/22 for baseline labs to be done which included a CBC (complete blood count) and CMP (comprehensive metabolic panel). The facility nurse initialed the lab work was completed on 3/20/22 per the Medication Administration Record. Review of the paper and electronic medical records revealed no laboratory results. There was no documentation in the progress notes to indicate if specimen collection was not obtained by laboratory staff or resident refused lab work. A copy of the lab results was requested from the Unit Manager (UM) of…

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.