Trevecca Center For Rehabilitation And Healing LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview the facility failed to make prompt efforts to resolve grievances for missing personal belongings for 2 of 3 sampled residents (Residents #36 and #155). The findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with a diagnosis which included Multiple Sclerosis. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. During an interview on 6/13/2023 at 10:28 AM, Family Member #6 stated she had reported to Licensed Practical Nurse (LPN) #1 Resident #36 was missing an electric razor charging cord. During a telephone interview on 6/14/2023 at 10:29 AM, LPN #1 stated Family Member #6 had gone to Resident #36's previous room and could not find the cord to his electric razor. LPN #1 told Family Member #6 to call the Housekeeping department…

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 provide a written bed-hold notice to the resident and the resident's representative at the time of hospitalization for 5 of 5 (Resident #91, Resident # 118, Resident #131, Resident #137, and Resident #224) sampled residents reviewed for hospitalization. Review of the facility policy titled, Bed-Holds and Returns, dated 5/18/2023 revealed, .Residents and /or representatives are informed [in writing] of the facility and state [if applicable] bed-hold policies .All residents/representative are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence [hospitalization or therapeutic leave] . Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Aftercare following joint replacement surgery, Type 2 Diabetes Mellitus with hypoglycemia,…

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 have a care plan conference meeting with the resident or resident's representative for 6 of 6 (Residents #30, #88, #91, #103, #137, #150) sampled residents reviewed. The findings include: Review of the undated facility policy titled Care Plans Comprehensive revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS (Minimum Data Set) assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission .Each resident's comprehensive person-centered care plan is consistant with the resident's rights to participate in the development and implementation of his or her plan of care . Review of the medical 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 facility policy review, observation, and interview, the facility failed to ensure 2 of 59 (Resident #11 and Resident #27) sampled residents received their showers/ baths as scheduled, and the facility failed to ensure 1 of 59 sampled residents (Resident #27) had clean and groomed fingernails. The findings include: Review of the policy titled, Bath, Shower/Tub dated 5/19/2023 revealed .The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Assist the resident into the bath chair, if applicable .Assist with dressing and grooming as needed .If resident refuses the shower/tub bath, the reason(s) why and the intervention taken .The signature and title of the person recording the date . Review of the policy titled, Activities of Daily Living (ADLs), Supporting dated 5/19/2023 revealed .Resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities 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 medical record review and interview, the facilty failed to ensure proper treatment and assistive devices to maintain vision for 1 of 59 (Resident #155) residents reviewed for visual decline. The findings include: Review of the medical record revealed Resident #155 was admitted on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included Generalized Epilepsy, Heart Failure, and Hypertension. Review of the Comprehensive Care Plan revealed Resident #155 had a focus for .resident has impaired visual function .arrange consultation with eye care practitioner as required . Review of the Nursing Progress Note dated 1/25/2022 revealed, .Resident informed nurse that he was concerned about his previous loss of vision to his right eye r/t [related to] a history of seizure activity. Resident expressed that he wanted to see a specialist for his eye. Signee informed resident that she would make NP [nurse practitioner] aware . Review of the Physician Progress Notes dated 8/3/2022 revealed .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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to follow physician orders for 1 of 1 sampled residents (Resident #219) related to therapeutic diet. The findings include: Review of the medical record revealed Resident #219 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Dysphagia, Unspecified Severe Protein-Calorie Malnutrition, and Hereditary Spastic Paraplegia. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed coughing or choking during meals or when swallowing medications and complaints of difficulty or pain when swallowing. Review of the physician's orders dated 6/8/2023, revealed .Regular diet Mechanically Altered Ground texture, Nectar Thickened Liquids consistency . Observation on 6/20/2023 at 10:29 AM, revealed Resident #219 drinking a [named brand supplement drink] drink while watching television. During an observation and interview on 6/20/2023 at 10:35 AM in the door way of Resident #219's room, Resident #219…

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 and medical record review, the facility failed to adequately monitor for side effects or behaviors for 1 of 6 sampled residents (Resident #27) reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Psychotropic Medication Use, dated 3/8/2023 revealed, .Residents will not receive medications that are not clinically indicated to treat a specific condition .Drugs in the following categories are considered psychotropic medication and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications .Antidepressants . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], and readmission on [DATE] with diagnoses which included Fracture of Tibia or Fibula following insertion of Orthopedic Implant, Infection of the Skin and Subcutaneous Tissue, Morbid Obesity, and Hypertension. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] 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.

Based on facility policy review, observation, and interview, the facility dietary department failed to maintain and serve hot food at or greater than 135 degrees Fahrenheit (F) for 1 of 2 meal service observed. The findings include: Review of the undated facility policy titled, Food Production and Food Safety revealed .All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 F . During an observation on 6/12/2023 at 11:17 AM in the dietary department, the Certified Dietary Manager (CDM) was taking temperatures of the food on the steam table. During observation and interview on 6/12/2023 in the dietary department beginning at 11:40 AM through 11:42 AM, with the CDM present, the mid-day meal trayline service was in progress. Further observations of food temperatures revealed the chicken noodle soup was 130 degrees F, tomato soup was 129 degrees F, and the vegetable beef soup was 129 degrees F. Further observation revealed one tray cart had already been sent to the 500 hall. During an interview on 6/14/2023 at 9:52 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, medical record review, and interview, the facility failed to accommodate dietary preferences for 5 of 5 (Resident #157, #170, #185, #186 and #194)sampled residents reviewed for dietary preferences. The findings include: Review of the facility policy titled, Resident Food Preferences, dated 5/18/2023, revealed, .determine current food preferences .If resident refuses or is unhappy with his or her diet, the staff will discuss a plan that the resident is satisfied with . Review of the facility's undated policy titled, Dining/Meal Service revealed, .A meal identification and food preferences card (meal ID (identification) card/ticket) will be used to properly identify each individual's needs, including food and beverage preferences .permanent meal ID card/ticket should include the name of the individual, diet order, beverage preferences, food dislikes and any other applicable diet information . Review of the medical record revealed Resident #157 was admitted to the facility on [DATE]…

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 dietary department failed to maintain and clean the range hoods during 1 of 3 observations. The findings include: Review of the undated facility's policy titled, Cleaning Instructions revealed .Stove hoods and filters will be cleaned according to a cleaning schedule, or at least monthly . During observation in the dietary department on 6/12/2023 10:31 AM, the range hood was covered with clear and shiny debris. During an interview on 6/12/2023 at 12:05 PM, the Certified Dietary Manager (CDM) confirmed the range hood was covered with clear and shiny debris. The CDM stated the hood was cleaned only twice a year. The last time it was clean was 2/9/2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to respectfully address 1 resident (#212) out of 45 residents requiring feeding assistance, referred to as a feeder. The findings include: Facility policy review, Quality of Life-Dignity, dated 2001 and revised 2009, revealed .Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs . Medical record review revealed Resident #212 was admitted to the facility on [DATE] with diagnoses which included Quadriplegia, Muscle Weakness, Depression, and Pain. Medical record review of Resident #212's Quarterly Minimum Data Set (MDS) dated [DATE], the Significant Change MDS dated [DATE], and the Annual MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicated the resident was cognitively intact. Further record review of the MDS revealed 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 facility policy review, medical record review, facility investigation review, observation and interview, the facility failed to investigate an incident which involved a non-facility hypodermic syringe for 1 resident (#13) of 69 reviewed. The findings include: Review of the facility policy Accidents/Incidents Investigations dated 10/7/17 revealed .An investigation of the accident/incident will be made by the designated staff person . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which included Hepatitis C (liver disease), Encephalopathy, Psychoactive Substance Abuse, and Generalized Anxiety Disorder. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Medical record review of the physician orders dated 2/16/19 revealed .Urine Drug Screen . Continued review revealed no orders for amphetamines. Medical 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 review of the facility staffing schedules and interview, the facility failed to provide sufficient staffing to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident on 3/11/18 for 1 floor (5th) of 4 floors reviewed. Findings include: Record review of the facility staffing for 3/11/18 revealed 4 Certified Nurse Aides (CNAs) were scheduled for the 7:00 PM to 11:00 PM shift with 56 residents on the 5th floor. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15/15, (cognitively intact), and required total 1 person assistance for toileting. Interview with Resident #63 on 3/12/18 at 8:29 AM in the resident's room on the fifth floor revealed .they are not answering the call light .takes 40-45 minutes to answer and I can't hold it and wet myself . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #54 had a BIMS score of 13/15,…

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 maintain a clean environment for 1 of 5 observed fans on the 5th floor. Findings include: Review of the facility policy Infection Control Standard Precautions effective date 11/1/07 revealed .Environmental Control .Ensure that environmental equipment and other frequently touched surfaces are appropriately cleaned . Observation on 3/12/18 at 3:12 PM in the room of Resident # 5 revealed a table top fan on the bed side table in operation and directed at the resident seated in power wheelchair. Further observation revealed the fan grate had a heavy accumulation of hanging debris. Interview with Assistant Director of Nursing #2 on 3/12/18 at 3:19 PM in Resident #5's room confirmed the fan was dirty and was directed toward the resident.