Tri State Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, electronic mail (email) communication review, facility documentation review, observation, and interviews the facility failed to protect residents' rights to be free from misappropriation of narcotic medications for 1 resident (Resident #17) of 19 residents reviewed for misappropriation.The facility was cited at F-602 as Past Non-Compliance.Non-compliance began on 11/10/2025 and ended on 11/21/2025. The findings include:Review of the facility's undated policy titled, Abuse: Prevention of and Prohibition Against, revealed .It is the policy of this Facility that each resident has the right to be free from .misappropriation of resident property .The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be [free] from .misappropriation of resident property .Misappropriation of resident property means the deliberate…

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 facility policy review, medical record review, observation, and interviews, the facility failed to follow a Physician's order for 1 resident (Resident #9) of 19 residents reviewed for medication administration.The findings include:Review of the facility's policy, titled Administering Medications undated revealed, .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders .Medications are administered as ordered .Right Patient .Right Med .Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety Disorder, Brief Psychotic Disorder, and Cognitive Communication Deficit.Review of the annual Minimum Data Set assessment dated [DATE], revealed Resident #9 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment indicating the resident was cognitively intact.During an observation on 12/16/2025 at 9:29 AM, revealed a clear medication cup 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 facility policy review, medical record review, observations, and interviews, the facility failed to ensure the safety of 1 resident (Resident #9) of 19 residents reviewed for accidents. The findings include:Review of the facility policy titled, Administering Medications undated revealed .Medications are administered in a safe and timely manner .The nurse providing/administering the medications will verify consumption compliance .Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety Disorder, Brief Psychotic Disorder, and Cognitive Communication Deficit.Review of the annual Minimum Data Set assessment dated [DATE], revealed Resident #9 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact.During an observation on 12/16/2025 at 9:29 AM, revealed a clear medication cup with 4 pills on Resident #9's bedside table. During an interview on 12/16/2025 at 9:39 AM,…

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 facility policy review, review of manufacturer guidelines, medical record review, observation, and interview the facility failed to store insulin pens appropriately for 3 residents (Resident #15, #25 and #78) on 1 medication cart of 3 medication carts observed for medication storage.The findings include:Review of the facility policy titled, Administering Medications, undated, revealed .Medications are administered in a safe and timely manner .When opening .the date opened is recorded on the container .Review of manufacturer guidelines, dated 7/2022, revealed .TRESIBA [medication used to treat Diabetes] .(insulin degludec) .should be thrown away after 56 days, even if it still has insulin left in it .Review of manufacturer guidelines, dated 5/2025, revealed .Lantus [medication used to treat Diabetes] Only use your pen for up to 28 days after its first use .Throw away the Lantus .pen you are using after 28 days .Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with…

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 facility policy review, medical record review, and interview, the facility failed to develop and implement a care plan to include the code status for 4 residents (Residents #3, #8, #9, and #10) of 5 residents reviewed for care plans. The findings include: Review of the facility policy titled, Care Planning - Interdisciplinary Team, dated 3/2022, revealed .The interdisciplinary team (IDT) is responsible for the development of resident care plans .Resident care plans are developed according to the time frames and criteria established .Comprehensive, person-centered care plan are based on resident assessment and developed by an interdisciplinary team (IDT) .The IDT includes but is not limited to .the resident's attending physician .a registered nurse with responsibility for the resident .to the extent practicable, the resident and/or the resident's representative . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Chronic Congestive Heart…

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 job description review, medical record review, facility documentation review, and interview, the facility failed to ensure medical records regarding Cardio-Pulmonary Resuscitation (CPR) were complete and accurate for 4 residents (Residents #3, #8, #9, and #10) of 5 resident medical records reviewed for CPR. The findings include: Review of a job description for the Licensed Practical Nurse (LPN) dated [DATE], revealed .ESSENTIAL DUTIES AND RESPONSIBILITIES .Perform administrative duties regarding assigned residents, such as completing medical forms, reports .Make written and oral reports .to the attending physician, Medical Director, or the Administrator concerning the status and care of the assigned resident .Review medication cards for completeness of information, accuracy in the transcription of the physician's order .Chart nurses' notes in professional and appropriate manner that timely, accurately and thoroughly reflects the care provided to the resident .Perform routine charting duties as required…

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 medical record review, facility investigation review, observations, and interviews the facility failed to ensure 2 residents (Resident #1 and Resident #2) were free from abuse of 5 sampled residents. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Aphasia, Hemiplegia and Hemiparesis affecting Dominate Right Side, Seizures, and Atherosclerotic Heart Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 9 on the Brief Interview Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Review of the comprehensive care plan for Resident #1 dated 3/11/2024, revealed the facility added a focus of a psychosocial well-being problem for Resident #1 with the intervention of a stop net to resident's door entry into his room. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including…

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 medical record review, observation, and interview the facility failed to follow physician's orders for a tube feeding for 1 resident (#35) of 6 residents reviewed for tube feeding. The findings include: Record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side, Type 2 Diabetes Mellitus, Dysphagia, and Dementia. Review of Resident #35's plan of care dated 5/26/2023 revealed, .Feeding Tube: The resident requires tube feeding .r/t (related to) history of Cerebral Infarction and Dysphagia . Review of the physician recapitulation orders active as of 8/16/2023 revealed .Give Diabetasource 1.2 [type of liquid nutritional replacement] via [by] pump at 90cc/hr [cubic centimeter per hour] x 22 hours .start date 5/12/2023 . Observation of Resident #35 on 8/15/2023 at 10:10 AM, in the resident's room, revealed Diabetasource 1.2 infusing at 85cc/hr. Observation with the Director of Nursing…

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 facility policy review, observation, and interview the facility failed to ensure 1 of 4 kitchen employees wore Personal Protective Equipment (PPE) appropriately while in the kitchen workspace. The findings include: Review of the facility policy titled, COVID-19 Prevention and Control: PPE Mask_When to use dated 5/2023 showed, .Policy Interpretation and Implementation .Infection prevention and control measures are based on established guidelines governing all communicable diseases .Source control for HCP [health care providers] include .A barrier face covering .A well-fitting facemask . During an observation on 8/14/2023 from 11:30 AM - 11:45 AM, the Temporary [NAME] (TC) #1 was observed not wearing a facial mask appropriately while in the kitchen (mask worn under the chin). TC #1 was observed collecting food measuring/serving utensils, removing covered trays of items from the reach in refrigerator, answering the backdoor doorbell and checking in covered loaves of bread with a food vendor. TC #1 delivered the invoice from the bread vendor to the Dietary Manager (DM) who 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 medical record review, observation, and interview the facility failed to follow a physician's order for 1 resident (#24) of 1 resident reviewed for tracheostomy care. The findings include: Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Sepsis, Type 2 Diabetes Mellitus, Chronic Pain, Subarachnoid Hemorrhage, Cerebral Edema, Acute Respiratory Failure, and Tracheostomy. Medical record review of a physician's order dated 10/8/19 revealed .TRACH [tracheostomy] [an opening in the neck to create an airway] CARE BID [two times a day] - CLEAN TRACH WITH H202 [hydrogen peroxide]/NS [normal saline] . Medical record review of the resident's Comprehensive Care Plan dated 5/1/19 revealed .Perform resident's trach care per MD (medical doctor) orders . Medical record review of the Treatment Administration Record (TAR) dated October, November and December of 2019 revealed the order for tracheostomy care was time coded as daily instead of BID as ordered.…

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.