Rehabilitation Center of The Palm Beaches, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to honor the resident representative's request to ensure, 1 of 3 sampled residents reviewed for Choices, Resident #71, received a shower on the scheduled shower days. The findings included: Record review documented Resident #71 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment done on 12/27/24 documented Resident #71 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment and the resident is dependent for all care needs. During an observation in the room of Resident # 71, there was a white sheet of paper posted on the bulletin board with the following handwritten message: please see that she (Resident #71) get a shower on her shower days. Review of the orders shows the resident's shower schedule is every Monday and Thursday on the 3 PM - 11 PM shift. Review of the documentation on the Certified Nursing Assistant (CNA) task list from 02/27/25 to 03/24/25…

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 accurately document the discharge status of 1 of 3 sampled residents reviewed as closed records, Resident #100. The findings included: Record review documented Resident #100 was admitted to the facility on [DATE] and discharged home on [DATE]. Resident #100's diagnoses upon admission included: Anemia, Hypertension, Hip fracture, Spondylopathy in lumbar region, Muscle wasting and atrophy, Abnormalities of gait and mobility, Obesity, and Chronic pain syndrome. Review of Resident #100's care plan for discharge, dated 01/14/25, documented, The resident wishes / or Responsible Party wishes to: return home. The goal of the care plan was documented as, Safely discharge to a lower level of care (Home, Home with Home Health Aide, Assisted Living Facility, Independent Living Facility, other) when rehab goals are met. Reivew of a progress note, dated 01/24/25, documented, Resident discharge from [name of facility] to home at 300 pm, VIA PRIVATE CAR accompanied,…

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 follow physician orders for 2 of 6 sampled residents, as evidenced by the topical cream for Resident #5 was not applied as ordered, and the blood pressure medication was not given as needed for Resident #58; and failed to follow physician orders to obtain a urology consultation as ordered for 1 of 2 sampled residents reviewed for catheters, Resident #63. The findings included: 1. Record review revealed Resident #5 was readmitted to the facility on [DATE]. Review of the current Minimum Data Sheet (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 05, on a 0 to 15 scale, indicating severe cognitive impairment. Review of a physician order dated [DATE] instructed the staff to apply an antifungal cream to the areas affected with a rash (skin condition) on the day (7 AM to 3 PM) and evening (3 PM-11 PM) shifts. Review of the care plan dated [DATE], documented Resident #5 was at risk…

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 interviews, the facility failed to provide adequate hydration for 1 of 1 sampled resident, as evidenced by not ensuring that Resident #16 was able to have the fluids she was allowed. The findings included: Record review revealed Resident #16 was admitted to the facility on [DATE]. Review of current Minimum Data Sheet (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 05, on a 0 to 15 scale, indicating severe cognitive impairment. Review of the physician order dated 02/27/25 instructed the staff that Resident #16 was on a 1200 milliliters per day fluid restriction with 900 milliliters to be given by dietary daily and 300 milliliters to be given by nursing daily. During an interview on 03/24/25 at 10:42 AM, Resident #16 stated, I was put on liquid restriction. I get 2 juices, 4 ounces at lunch and dinner. I leave it on my table to sip on it throughout the day and the aides always take it away. They have been asked…

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 physician visits in a timely manner for 1 of 2 sampled residents reviewed for catheters, Resident #63. The findings included: Record review revealed Resident #63 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and was dependent on staff for activities of daily living (ADLs). The record revealed Resident #63 was hospitalized on [DATE], and readmitted to the facility on [DATE]. Review of Resident #63's physician progress notes revealed a progress note dated 11/07/24. There was no further evidence the resident was seen or evaluated by a physician between 08/24/24 through 11/07/24. An interview was conducted with the Director of Nursing (DON) on 03/27/25 at 10:00 AM, who acknowledged the above finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide notification to the residents' representative after a change in condition for 2 of 23 sampled residents, Residents #31 and #3. The findings included: Review of the facility policy, titled, Fall and Injury Reduction Policy, effective March 2023, documented, in part, Notify the resident representative of the fall, new intervention, and/or care given, or location transferred. The facility's policy titles, Notification of Resident/Patient Change in Condition, effective October 2021, documented, in part: Policy: Nurses will notify the resident / resident representative, if there is a crucial / significant change in the resident condition. If the change int eh resident's condition is not crucial or significant, the resident's Physician, resident representative or legal representative will be notified at the earliest convenient time during regular business hours. Procedure: 1. Notify the Physician resident/resident representative, 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 interviews, record review and policy review, the facility failed to provide necessary treatment and services to prevent worsening of a pressure ulcer for 1 of 2 sampled residents sampled for pressure ulcers (Resident #254). The findings included: The Policy and Procedure, titlesd, Treatment Protocols for Stage III and Stage IV Pressure Area or Full Thickness Wounds with No Drainage (Shallow or Deep), effective October 2021, documented, Review support surface guideline to ensure the Resident / Patient receives the benefit of a therapeutic bed surface when clinically necessary. Review of the record revealed Resident #254 was initially admitted to the facility on [DATE]. The resident had multiple hospitalizations during her residence at the nursing home and was transferred to the hospital on [DATE] and did not return to the facility. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 04/01/23 documented a Brief Interview for Mental Status (BIMS) score of 9, indicating…

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 maintain accuracy of records for 3 of 23 sampled residents, Residents #3 #79, and #95. The findings included: Review of the facility's policy, titled, Late Entry, Addendum, Corrections and Clarification, with an effective date of June 2022, included: The facility will utilize the following procedures when documentation problems or mistakes occur, and changes or clarifications are necessary. Late Entry: At times it will be necessary to make an entry that is late (out of sequence) to provide additional documentation to supplement entries previously written. When a pertinent entry was missed or not written in a timely manner, a late entry will be used to record the information in the medical record. Guidelines Late Entry 1. Document the late entry as soon as possible timeframe. 2. Record the late entry on the next available chronological line of the applicable form. 3. State Late Entry at the beginning of the documentation. 4. Enter 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, record review and policy review, the facility failed to accurately assess and reassess the efficacy of interventions for skin rash for 1 of 1 sampled resident, reviewed (Resident #92); and failed to provide post-op surgical care for 1 of 1 sampled resident, reviewed (Resident #82). The findings included: 1. During the initial screening of residents on 08/01/22 at 1:50 PM, Resident #92 was observed to have a reddened raised rash on both his arms, as well as linear scratches in the same areas. Record review on 08/02/22 revealed Resident #92 was admitted on [DATE] with a primary diagnosis of Osteomyelitis, non-healing pressure ulcers, Diabetes, and the relevant diagnosis of Pruritis. The admission comprehensive assessment documented the BIMS (Brief Interview of Mental Status) exam score of 15/15 showing no cognitive decline. Known allergies to heparin, penicillin and sulfa were also noted. The admission summary, dated [DATE] at 11:54 PM, noted a general body rash and multiple dry…

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 document the location of pain for 1 of 1 sampled resident reviewed as a closed record (Resident #96); and failed to document a change in condition for 1 of 5 sampled residents reviewed for Covid-19 (Resident #21). The findings included: 1. Resident #96 was admitted to the facility on [DATE], with diagnosis that included right femur fracture. A comprehensive assessment, dated [DATE], documented the resident had mild cognitive impairment, and required extensive 1-2 person assist with activities of daily living. Resident #96 was care planned for pain or a potential for pain related to a history of fall with a fractured femur. An intervention included to observe and report signs and symptoms of pain and worsening of pain. Report changes in pain location, type, frequency, and intensity. A review of Resident #96's physician orders revealed an order, dated [DATE], to monitor pain every shift and report pain number on a 0-10 scale for pain monitoring. A 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.