Polo Rehabilitation & Hcc

Based on interview and record review, the facility failed to have an Infection Preventionist. This failure had the potential to affect all 29 facility residents. The findings include: The facility's 5/3/23 Resident Census and Condition of Residents form showed 29 residents in the facility. On 05/03/23 at 09:53 AM, V6 MDS nurse said she was unable to locate her Infection Preventionist (IP) Certificate. At 09:55 AM, V1 Administrator said she could not produce her IP certificate. On 05/04/23 at 08:50 AM, V1 said she it's important to have an IP on staff to monitor and track illnesses trends for infectious diseases, minimize the risk of the spread of infection, and to monitor immunizations to prevent complications. The facility's 4/11/22 Infection Control Surveillance and Monitoring Policy showed the facility shall employ at a minimum, a part-time Infection Control Preventionist. The facility's 3/3/23 Infection Preventionist Job Description showed the Infection Preventionist (IP) is accountable for decreasing the incidence and transmission of infectious diseases between residents,…

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 controlled medications were reconciled in a manner to prevent diversion for 3 of 3 residents (R79, R4, R13) reviewed for medication storage in the sample of 13 and failed to ensure a resident's pain medication was available for use for 1 of 1 resident (R83) reviewed for pain medications in the sample of 13. The findings include: On 05/02/23 at 08:53 AM, during the medication storage task with V3 Registered Nurse (RN) there were three boxes in the medication refrigerator. One box had R79's information on the label and included a sealed 15 milliliter (ml) bottle of morphine sulfate 100 milligrams (mg) per 5 ml oral solution and a sealed 30 ml bottle of lorazepam 2 mg per ml oral solution. Neither bottle had a reconciliation form to show it was controlled and accounted. A second box had R4's information on the label and contained a sealed 5 ml bottle of morphine sulfate 20 mg per ml oral solution and a sealed 5 ml bottle of lorazepam…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure personal cares were performed in a manner to maintain residents' dignity for 2 of 2 residents (R79, R2) reviewed for dignity in the sample of 13. The findings include: 1. R79's admission Record, printed by the facility on 5/3/23, showed she had diagnoses including Alzheimer's disease with early onset, major depressive disorder, and anxiety disorder. R79's baseline Care Plan dated 4/18/23, showed she was dependent on 2 staff members for toileting and bathing. The assessment showed R79 was dependent on one staff for dressing. On 5/2/23 at 10:32 AM, V15 (Hospice CNA-Certified Nursing Assistant) exited R79's room with R79 sitting in a shower chair. R79 was naked from the waist down. A blanket was on R79's lap, covering her front area and legs. R79's buttocks was not covered and could be clearly seen from the nurse's desk. On 5/4/23 at 9:19 AM, V5 (CNA) said it is important to make sure a resident's body is covered when you are…

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 identify the use of physical restraints and failed to follow their policy for restraints for 2 of 2 residents (R2, R79) reviewed for physical restraints in the sample of 13. The findings include: 1. R2's face sheet printed on 5/3/23 showed diagnosis including but not limited to rhabdomyolysis (severe muscle breakdown), dementia, multiple sclerosis, epilepsy, gastrostomy status, and history of cerebral infarction. R2's facility assessment dated [DATE] showed severe cognitive impairment and requires total staff assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. The same assessment showed R2 is always incontinent. The assessment showed R2 was not using any type of physical restraint. On 5/2/23 at 9:36 AM, R2 was transferred from the bed to her wheelchair using a mechanical lift. V5 and V11 (CNAs-Certified Nurse Aides) reclined the high back wheelchair slightly and clipped a seat belt…

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 ADL (Activities of Daily Living) care was provided for 1 of 1 resident (R19) reviewed for activities of daily living in the sample of 13. The findings include: R19's face sheet printed on 5/3/23 showed diagnoses including but not limited to Huntington's Disease, muscle weakness, insomnia, gastrostomy status, and dysphagia. R19's facility assessment dated [DATE] showed no cognitive impairment and staff assistance needed for bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. R19's ADL report for April 2023 showed total staff dependence for oral hygiene. On 5/2/23 at 9:52 AM, R19 was seated in a wheelchair in her room. R19 was alert and able to nod yes or no in answer but was non-verbal. R19's teeth, tongue, and lips were covered with a yellowish, crusty substance. R19's call light was lying on the floor, underneath her bed. At 9:55 AM, V5 (Certified Nurse Aide) said R19 can express her needs and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to document an assessment of a pressure area and develop a care plan for 1 of 1 resident (R21) reviewed for pressure ulcers in the sample of 13. The findings include: R21's admission Record, printed by the facility on 5/4/23, showed she was admitted to the facility on [DATE] with diagnoses including anemia, muscle spasm, malignant neoplasm of exocervix (the outer part of the cervix that opens into the vagina), obstructive (a condition in which urine cannot flow, either partially or completely, through the ureter, bladder or urethra due to some type of obstruction) and reflux uropathy (a condition in which the kidneys are damaged by the backward flow of urine into the kidney). R21's facility assessment dated [DATE] showed she was cognitively intact. The assessment showed R21 required extensive assist of two staff members for bed mobility and dressing, extensive assist of one staff member for personal hygiene, and was dependent on two staff…

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 transfer a high fall risk resident safely and failed to ensure a resident did not hold smoking materials for 2 of 2 residents (R10, R82) reviewed for safety in the sample of 13. The findings include: 1. R10's face sheet printed on 5/3/23 showed diagnoses including but not limited to metabolic encephalopathy, muscle weakness, difficulty walking, unsteadiness on feet, and altered mental status. R10's facility assessment dated [DATE] showed total dependence on staff for transfers and toilet use. The same assessment showed R10 is always incontinent of urine and bowel. R10's Fall Risk assessment dated [DATE] showed a high risk for falls. The facility supplied fall log showed R10 has fallen five times within the last three months. On 5/2/23 at 9:02 AM, V5 and V7 (CNAs-Certified Nurse Aides) entered R10's room and wheeled her to the bathroom. V5 assisted R10 to stand and pivot to the toilet while holding her arm. V5 assisted R10 back into her…

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 have an order for dialysis on a resident's Physician's Order Sheet (POS) and failed to develop a dialysis care plan for 1 of 1 resident (R 81) reviewed for dialysis in the sample of 13. The findings include: R81's admission Record, printed by the facility on 5/4/23 showed R81 was admitted to the facility on [DATE] and had diagnoses of end stage renal disease, chronic kidney disease, depression, muscle weakness, major depressive disorder, type II diabetes mellitus, and other disorders of electrolyte and fluid balance. R81's facility assessment dated [DATE] showed he was cognitively intact and required extensive assist of two staff members for bed mobility and toileting. The assessment showed R81 was dependent on staff members for transfers, dressing and bathing. The assessment also showed that R81 was receiving dialysis. On 5/2/23 at 1:18 PM, R81 was in his room, sitting in his wheelchair. R81 said he had just got back from having dialysis…

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 were offered immunization for influenza and pneumonia and failed to obtain historical immunization data for 3 of 5 residents (R21, R79, R81) reviewed for immunizations in the sample of 13. The findings include: On 05/03/23 at 03:08 PM, V8 Regional Director of Operations said there were no consents, historical data, or evidence of immunization for pneumonia or influenza being offered for R21, R79, and R81. On 05/04/23 at 08:50 AM, V1 said she it's important to ensure residents have their immunizations or at least offered and up to date. If residents are not immunized there is an increased risk of them becoming ill, an increased for spreading disease, and making them more susceptible to complications of infectious diseases. The residents live in a high risk environment and being immunized decreases their likelihood of getting flu & pneumonia. The resident immunization review in the infection control task revealed the facility had no…

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.

2. On 2/7/22 at 9:44 AM, V6, License Practical Nurse (LPN) was the nurse working in the Covid Unit. V6 had four residents in the Covid unit and Isolation unit, R3, R19 (both COVID positive) and R4, R77 (both PUI). V6 was wearing a surgical mask under her N95 mask. V6 said she prefers to put her surgical mask first then apply the N95 mask. V6 said that was how she wears her PPE. V6 was also the nurse working in the B wing (non-isolation unit). On 2/7/21 at 12:31 PM, V2 (DON) said it does not matter to her how staff wear their mask, they can put surgical mask under the N95 or over the N95. V2 said she would rather have staff wear a surgical mask and a N95 over it, research has not shown there is a difference. On 2/8/21 at 2:36pm PM, V8 (Regional Nurse) said staff should not put anything under the N95 mask so not to break the seal to prevent the spread the infection particularly COVID-19. A facility document entitled CDC Respirator-On with training date of 3/8/21 show Do not allow anything between your face and the respirator. (N95 Mask). Based on observation, interview and record…

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 test an unvaccinated employee for COVID-19 twice a week as required for a high community transmission rate. This has the potential to affect all 29 residents that reside at the facility. The findings include: The Resident Census and Conditions of Residents (Form CMS 672) dated 2/8/22 shows that there were 29 residents residing in the facility. The undated facility provided COVID-19 Positive Staff list shows that an outbreak started on 12/9/21 when an employee tested positive for COVID-19. The undated facility provided COVID-19 Positive Residents list shows that 17 additional residents tested positive on 12/9/21. On 2/7/22 at 1:24 PM, V2 (Director of Nursing) said that they are doing twice a week testing on all staff members due to the community transmission rate being high and they are in an outbreak that started on 12/9/21. V2 said that they have had high community transmission since she started at the facility in August. The facility's…

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 offer and administer pneumococcal conjugate vaccine (PCV13) and Pneumococcal polysaccharide vaccine (PPSV23) for 4 of 5 residents (R4, R6, R12 and R17) reviewed for immunizations in the sample of 14. The findings include: 1. R12's Face Sheet shows that he was admitted to the facility on [DATE]. R12's Immunization Record shows, Unknown for Pneumococcal record. On 2/9/22 at 9:30 AM, V2 (Director of Nursing) said that she spoke to R12's Power of Attorney today and they would like vaccine series started. 2. R6's Face Sheet shows that she was admitted to the facility on [DATE]. R6's Immunization Record shows, Unknown for Pneumococcal record. 3. R4's Face Sheet shows that he was admitted on [DATE]. R4's Immunization Record shows that she received PPSV23 on 11/3/20. There is no documentation that she received the PCV13 dose. 4. R17's Face Sheet shows that she was admitted to the facility on [DATE]. R17's immunization Record shows that she received PPSV23 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to do quarterly assessment for restraints; and failed to obtain a consent for the use of restraints for 2 of 3 residents (R21 and R20) reviewed for restraints in the sample of 14. The findings include: 1. On 2/7/22 at 9:43 AM, R21 was in his room sitting in his wheelchair. R21 has a seat belt secured around R21's waist. R21 stated, I don't know why it's with me, (pointing to the seatbelt) someone has the key to remove this belt, they want me to stay here in this chair, I can't remove this by myself On 2/8/22 at 9:21 AM, R21 was up in his wheelchair in his room with the seat belt secured around his waist. On 2/7/22 at 11:00 AM, V6, License Practical Nurse (LPN) was in R21's room. V6 asked R21 to remove the belt. R21 stated where? here? I don't know! V6 repeatedly gave R21 instructions to remove the belt but R21 was unable to remove the belt as instructed. V6 said R21 has had this seatbelt restraint for years now. R21's Physical…

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 incontinence care for residents who need extensive assistance, and failed to provide oral care for three of 14 residents (R20, R12, and R17) in the sample of 14. The findings include: 1. On 2/7/22 at 2:22 PM, V4 CNA was performing incontinence care for R20. R20's mechanical lift sling was wet. R20's buttocks and frontal peri area was reddened. V4 did not place any protective cream to R20's buttocks. V4 said staff on third shift got R20 out of bed. R20's Care Plan with a start date of 1/15/18 shows, [R20] is at risk for skin breakdown related to immobility, right hemiparesis with contractures to right hand/wrist, diabetes, and episodes of bladder incontinence. Frequently gets rash like area near coccyx and back of upper thighs. R20's MDS (Minimum Data Set) dated 1/1/22 shows R20 requires extensive assist in bed mobility and total assistance in toilet use and personal hygiene. R20 is always incontinent of stool. 2. On 2/7/22 at 2:58…

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 a resident's feet were not up against a foot board to prevent redness, and failed to ensure dressings were maintained for three wounds for two of 14 residents (R12, R20) reviewed for quality of care in the sample of 14. The findings include: 1. R12's Report of Monthly Weight and Vitals sheet shows R12 is 74 inches long (Over six feet tall). R12's Physician Orders Sheet dated 2/1/22-2/28/22 shows, Float heels while in bed. R12's Progress Notes dated 8/5/21 shows, [R12] is a tall man and could benefit from a longer bed and/or foot board. On 2/7/22 at 12:00 PM, R12's legs were bent and his feet were pressed up against the foot board of his bed. At 2:58 PM, during incontinence care, R12's feet were still pressed up against the foot board of his bed. V4 CNA (Certified Nursing Assistant) said that R12 used to have a longer bed, but something broke on it. On 2/8/22 at 11:51 AM, R12's legs were bent and his feet were pressed up against the foot board of his bed. V20 RN (Registered Nurse) said that the 2nd and…

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

Based on observation, interview, and record review the facility failed to ensure a resident with a contracture had a splint applied for one of three residents (R12) reviewed for contractures in the sample of 14. The findings include: On 2/7/22 at 12:00 PM, R12's right hand was contracted and had no splint in place. At 2:58 PM R12 still did not have a splint in place. On 2/8/22 at 11:51 AM, R12 did not have a splint in place to his right hand. V7 CNA (Certified Nursing Assistant) said R12 has a splint that he uses periodically, but V7 did not know when R12's splint is applied. On 2/8/22 at 12:16 PM, V2 DON (Director of Nursing) said, R12 has a splint that get put on for up to six hours once or twice a day per therapies orders. V2 said therapy does not see R12 anymore but did instruct staff how to put the splint on. Placing the splint should be a part of the CNAs get up plan in the morning. V2 said R12's splint should be placed on in the morning. V2 said there is no way to document that the splint is in place. The staff just know to put it on when they get him [R12] dressed in 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 reposition residents in a safe manner and failed to ensure fall prevention interventions were in place to a resident with previous falls and high risk for falls for three of 14 residents (R12, R7, R14) reviewed for safety in the sample of 14. The findings include: 1. R7's Physician Orders dated 2/1/22-2/28/22 shows R7 was admitted to the facility on [DATE] with diagnoses including: Seizures, weakness, multiple sclerosis, neurogenic bladder, and spastic paraparesis. R7's MDS (Minimum Data Set) dated 1/17/22 shows total dependence of two staff for bed mobility. R7's MDS shows that R7 has a limited range of motion to both upper and lower extremities. R7's Care Plan started 2/21/17 shows R7 is at risk for falls related to multiple sclerosis with spastic paraparesis and generalized weakness. R7's Care Plan does not address R7's current ADLs assistance needs. R7's care plan does not reflect that R7 currently uses a mechanical lift for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter was kept below the level of the bladder for one of two residents (R20) in the sample of 14. The findings include: R20 Physician Orders dated 2/1/22-2/28/22 shows R20 was admitted to the facility on [DATE] with diagnoses including: Sepsis, kidney stones, right hemiparesis, and urinary tract infection (UTI). On 2/7/22 at 2:22 PM, V4 CNA (Certified Nursing Assistant) lifted R20's urinary drainage bag above the level of R20's bladder while she was pulling the bag through R20's pants. There was dark urine in R20's urinary drainage bag. R20 placed the urinary drainage bag on top of R20's bed while she finished cares. On 2/9/22 at 9:50 AM, V10 CNA said the catheter bag should be kept below the level of the resident's bladder. The facility's Catheter Care policy revised 12/8/10 does not include interventions to keep the urinary drainage bag below the level of the bladder.

Based on interview and record review the facility failed to to ensure psychotropic medications had a duration end date for 2 of 5 residents (R22, R6) reviewed for unnecessary medications in the sample of 5. The findings include: On 02/08/22 AM, at 9:11 AM, review of R22's Physician Order Sheet (POS) show, R22 has an order of : Order date: 1/14/22 - Xanax (anti-anxiety psychotropic medication) 0.25 mg BID as needed for anxiety, no stop date/duration. On 02/08/22 at 08:41 AM, review of R6's POS show R6 has an order of: Order date, 9/9/21-Lorazepam (anti-anxiety psychotropic medication) give 0.25mg every 2 hours as needed for agitation, with no stop date/duration. On 2/8/22 at 12:36 PM, V2 Director Of Nursing (DON) said she knew psychotropic medications need to have stop dates. The facility policy entitled Psychotropic Medication dated 11/17 show, PRN orders for psychotropic medications- time limitations 14 days.