Henry Rehab And Nursing

Based on observation, interview and record review the Facility failed to promptly respond and resolve Resident Council concerns in a timely manner for five of five Residents (R1, R2, R31, R40 and R41) reviewed for Resident Council concerns in a sample of 28.Findings include:The Facility Resident and Family Concerns and Grievances Policy, revised 10/5/23, documents: prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with Federal and State statutes and regulations; Facility is committed to ensure the continued provision of such exceptional care and services and has established grievance process to address Resident and family member concerns or dissatisfaction about the Facility provision of care and services; should a Resident require assistance in voicing a grievance the Facility associates shall provide needed assistance; the management or supervisory staff will commence a formal investigation of the grievance as is practicable; and will follow-up with Resident or their family/guardian within 72 hours of the filing of 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 observation, interview and record review the Facility failed to follow a care planned dysphagia diet intervention and monitor/supervise one of 15 Residents (R7) reviewed for diets in a sample of 28. Findings include:The Facility Aspiration Precautions Policy, revised 2/11/26, documents: it is the policy of this Facility that Residents will be identified when they are at risk for aspiration and that the plan of care will reflect appropriate interventions; any resident identified as an aspiration risk will be placed on Aspiration Precautions protocol; Aspiration Precaution protocol may include interventions determined by a Speech and Language Pathologist and Physician; Aspiration Precautions will be noted on the resident plan of care; staff responsible for feeding will be knowledgeable of emergency procedures; resident will be in view of staff for meals and nourishments unless otherwise specified in the plan of care; and resident will be monitored for changes in their condition that would require further evaluation and intervention.R7's current Care Plan documents: Regular…

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 develop comprehensive care plans for three residents (R6, R22, R31) identified as requiring Contact Precautions of five residents reviewed for Transmission Based Precautions in a total sample of 22. FINDINGS INCLUDE: The facility policy, entitled Comprehensive Care Plan Policy, dated 6/25/2020, documents: An individualized comprehensive care plan that include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan has been designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems. R6's current Physicians Order Summary Report indicates R6 has diagnoses to include ESBL (Extended Spectrum Beta Lactamase Resistance and Urinary Tract Infection (UTI) and indicates R6 has Infection Precautions-Contact for ESBL in urine. (date initiated 5/16/24). R22's current Physicians Order Summary Report indicates R22 has diagnoses to include ESBL…

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 obtain smoking agreements and collect smoking paraphernalia for two (R1, R15) of two residents reviewed for smoking in a sample of 22. Findings include: The facility policy and procedure titled, Smoking, revised October 1, 2024, documents, Policy- To ensure compliance with regulatory guidelines and safety protocols, the Facility prohibits smoking except for in specifically designated areas. To protect the safety of other residents and employees, the use of medical oxygen is prohibited in smoking areas. Residents deemed to need assistance to smoke should have this designation noted in the care plan. For purposes of this policy, electronic cigarettes Ce-cigarettes, pipes, cigars, and similar paraphernalia are to be treated as cigarettes. Procedure- 1. B. Residents are not permitted to have any smoking paraphernalia in their room or on their person. All smoking paraphernalia should be given to the nursing staff for safekeeping. Nursing staff should maintain records of residents' property and distribute it…

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, observation, and record review the facility failed to attempt gradual dose reduction for one resident (R15) of five residents reviewed for unnecessary medications in a sample of 22. Findings include: The facility's Policy and Procedure, titled Psychotropic Gradual Dose Reduction (GDR), revised 11/5/19, documents, Policy statement- It is the policy of this facility that residents who use psychotropic drugs will receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue the use of these medications. Policy Interpretation and Implementation- 1. Residents who use psychotropic drugs will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. 4. Our drug reduction program consists of tapering the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether. Inquiries concerning drug reductions should be referred to the pharmacist, attending physician,…

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 provide a Hospice created Care Plan, visit communication notes and to designate in writing a facility Hospice Coordinator for one resident (R28) of three residents reviewed for Hospice in the sample of 22. FINDINGS INCLUDE: Facility Policy Hospice Care, dated 11/5/2019, document: This facility will work in coordination with the contracted Hospice agency to provide a safe continuum of care for the resident's end of life. Nursing Facility Hospice, General Inpatient And Respite Care Services Agreement, dated 7/13/21, documents: Services to be Provided by Hospice: Hospice will develop, at the time a resident of the Facility is admitted into Hospice's program, a Plan of Care for the management and palliation of the resident's terminal illness. The Plan of Care will identify the care and services that are needed and will specifically identify which provider is responsible for providing respective functions that have been agreed upon and included in the Plan of Care. The Plan of Care will be updated as often as the patient…

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 its policy of implementing care plan interventions to prevent the further decline of pressure ulcers, for one of three residents R100 reviewed for pressure ulcers, in a sample of 31. FINDINGS INCLUDE: The facility policy, Skin Prevention, Assessment and Treatment, dated (revised) May 2, 2022 directs staff, Purpose: To identify factors that place the residents at risk for the development of pressure ulcers; To implement appropriate interventions to prevent the development of clinically avoidable wounds; To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown; To promote healing of existing pressure ulcers. Residents identified as high risk should be addressed in the resident's care plan to assure appropriate interventions to manage the risk are implemented. Care Plan interventions include: Wound Consultant review; Registered Dietician review; Nutritional…

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

Based on record review and interview, it was determined the facility failed to ensure weights were obtained as ordered for 1 of 1 (R10) resident reviewed for Heart Failure in a sample of 31 residents. Findings include: The Minimum Data Set (MDS) section I documents R10 has an active diagnosis of Heart Failure. The current care plan documents R10 has an alteration to my cardiac system and to monitor vital signs as ordered and PRN (as needed); expect weight fluctuations due to edema and diuretics (medication that helps reduce fluid in the body). On 3/11/24, the Physician ordered weights to be conducted daily. Daily weights were not conducted in March 2024, 6 of 20 days. On 4/2/24 at 2:00 PM, V2 (Director of Nurses) stated R10's weights were not recorded daily and should have been.

Based on observation, interview and record review the facility failed to document target behaviors to warrant the use of Seroquel (antipsychotic medication) for one of two residents (R14) reviewed for antipsychotic medications in the sample of 31. Findings include: The facility's Psychotropic Medication Management policy, dated 12/4/19, documents Purpose to provide guidance for the psychopharmacologic drug treatment for a resident with specific conditions, including but not limited to dementia and other cognitive disorders, and/or behaviors as documented in the resident's clinical record. An assessment must be conducted to identify specific behaviors/ symptoms, potential causative factors and recommendations for managing identified behaviors. The physician should evaluate use of antipsychotic medication use if one or more of the following is/are the only indication: Wandering, Poor self-care, Restlessness, Impaired Memory, Anxiety, Depression (without psychotic features), Insomnia, Unsociability, Indifference to surroundings, Fidgeting, Nervousness, Uncooperativeness or Agitated…

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 Personal Protective Equipment was utilized and hand hygiene was performed for 3 of 6 residents (R10, R22 and R27) reviewed for Infection Control Practices in a sample of 31. Findings include: The Hand Washing policy dated 11/5/19, documented Hands should be washed before resident care, after resident care. The Enhanced Barrier Precautions policy dated 3/27/24, documented Are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or patient's environment. In addition to residents who have an infection or colonization with CDC (Center for Disease Control)-targeted or other epidemiologically important MDRO when contact precautions do not apply. Hand Washing. R10 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Atrial Fibrillation, history of Urinary Tract Infection (UTI) with Multi-Drug Resistant Organism and Acute Respiratory Failure. On 2/14/24,…

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 interview and record review, the facility failed to provide daily housekeeping cleaning services for one resident (R1) of four residents reviewed for housekeeping in a sample of four. Findings include: The facility's Resident Rights Policy and Procedure, Undated, documents: Purpose: To ensure the preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. IX. Safe environment. Each resident has a right to a safe clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safety. The facility shall provide: A. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belonging to the extent possible. B. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The facility's Effective Plan for Housekeeping Policy, dated 3/23/23, documents:…

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.