Roman Eagle Rehabilitation And Health Care Center

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. The findings included: The facility staff failed to ensure that 4 male facility staff members hair was secured while working in the facility kitchen. On 10/31/18 at 11:25 am, the surveyor observed a facility maintenance employee working on electrical outlet in the facility kitchen. The surveyor observed that the maintenance employee's hair and facial hair was not secured with a hair net or beard guard. The surveyor also observed Dietary Staff # 1 and Dietary Staff # 2 wearing beard guards, however, their mustaches were uncovered. Dietary Staff # 3 was observed to have a mustache and was not wearing a beard guard to keep facial hair contained. On 10/31/18 at 11:50 am, the surveyor spoke with the dietary services manager about the males in the kitchen hair not being properly secured. The dietary services manager agreed that the facility maintenance employee and dietary staff # 1. # 2, 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 staff interview and clinical record review, the facility staff failed to protect a resident's right to be free from misappropriation of resident property and/or exploitation on 7 of 8 nursing units in the facility. (East Wing, Mid-East, South Wing, Rehab, South Terrace, Garden Terrace and North Terrace Nursing Units) 1. The facility staff misappropriated 12 resident's (Resident #161,Resident #19, Resident #90, Resident #91, Resident #111, Resident #152, Resident #163, Resident #205, Resident #238, Resident #253, Resident #257 and Resident #344) narcotics when the nursing staff on East Wing, Mid-East, South Wing and the Rehab nursing units used prescription dispensed medications for 16 residents ( Resident #18, Resident #19, Resident # 145, Resident #170, Resident #171, Resident #185, Resident #238, Resident # 345, Resident #346, Resident #347, Resident #348, Resident #349, Resident #350, Resident #351, Resident #352, Resident #544 and Resident #545) without gaining their permission to use their…

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 3. The findings included: The facility staff failed to document the distribution of Norco on the narcotic sign off sheet for Resident # 545. Resident # 545 was a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to: chronic pain syndrome, type 2 diabetes mellitus, hypothyroidism, and diabetic neuropathy. The clinical record for Resident # 585 was reviewed on 10/31/18 at 9:14 am. During the time of the survey, there was no completed MDS assessment for Resident # 585. The plan of care for Resident # 585 was reviewed and revised on 10/24/18. The facility staff documented a focus area for Resident # 585 as, Resident # 585 has chronic pain. Interventions included but were not limited to: Administer pain medication as needed. Resident # 585 had current orders that were initiated by the physician on 10/25/18 for Norco 7.5-325 mg (milligram) tablet-give one tab (tablet) po (by mouth) tid (three times daily) PRN (as needed) x 10 days for pain. On 10/31/18 at 9:14…

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 staff interview and clinical record review, the facility staff failed to ensure routine physician ordered medications were available for administration on 7 of 8 nursing unit in the nursing facility. (South Wing, East Wing, Mid-East Wing, Rehab Wing, South Terrace, Garden Terrace and North Terrace) 1. The facility staff failed to ensure routine physician ordered medications were available for administration and not having to borrow from other resident's in the facility that involved a 27 residents. (Resident #161,Resident #19, Resident # 90, Resident #91, Resident #111, Resident #152, Resident #163, Resident #205, Resident #238, Resident #253, Resident #257, Resident #344, Resident #18, Resident # 145, Resident #170, Resident #171, Resident #185, Resident # 345, Resident #346, Resident #347, Resident #348, Resident #349, Resident #350, Resident #351, Resident #352, Resident #544 and Resident #545) The pharmacist failed to reconcile narcotic sheets with the above documented residents and failed to keep…

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 staff interviews and clinical record reviews, the facility staff failed to identify discrepancies on the narcotic sheets involving residents on 7 of 8 nursing units in the facility. (South Wing, East Wing, Mid-East Wing, Rehab Wing, South Terrace, Garden Terrace and North Terrace) 1. The staff pharmacist failed to identify discrepancies on the monthly drug regimen review for the residents on South Wing, East Wing, Mid-East Wing and the Rehab Wing. Resident #161 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, diabetes, Alzheimer's Disease, stroke, anxiety and depression. On the quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/11/18 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #161 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and totally dependent on 1 staff member for bathing. 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, staff interview, facility document review and clinical record review, the facility staff failed to store and date medications when opened on 5 of the 7 units. The findings included: 1. The facility staff failed to date medications when opened and failed to remove expired medications from the medication refrigerators on South Terrace and Garden Terrace for 4 residents (Resident #106, Resident #18, Resident #280, and Resident #136). (a) The surveyor observed the medication refrigerator on South Terrace with licensed practical nurse #2 on 10/30/18 at 4:09 p.m. In the refrigerator was Novolog insulin flex pen for Resident #106. The Novolog flex pen had been opened 9/27/18 and the expiration date was 10/25/18. The surveyor asked L.P.N. #2 what the protocol was for insulins that had expired. L.P.N. #2 stated the pharmacy needed to be called so a new flex pen could be used. Resident #106's clinical record was reviewed 10/30/18 through 11/2/18. Resident #106 was admitted to the facility 9/6/14 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 observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure the dignity of 3 of 39 residents was maintained (Resident #18, Resident #285, and Resident #55). The findings included: 1. The wound care registered nurse #1 signed the tape after the tape had been applied to Resident #18's dressings on both legs. Resident #18 was admitted to the facility 11/12/14 with diagnoses, that included but not limited to peripheral vascular disease, cellulitis, chronic venous hypertension with ulcer of left lower extremity, major depressive disorder, obesity, type 2 diabetes mellitus, hypertension, hypothyroidism, and edema. Resident #18's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/16/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #18's current comprehensive care plan dated 2/4/18 identified the resident to be at risk for skin breakdown per Braden scale-13. Interventions…

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 resident interview, staff interview, and clinical record review, facility staff failed to provide for the resident's right to choose activities and associates within the community for 1 of 39 residents in the survey sample (Resident #263). Resident #263 was admitted to the facility on [DATE]. Diagnoses included hypertension, obstructive uropathy, cerebrovascular accident, non-Alzheimer's dementia, hemiparesis, depression, spinal stenosis, chronic ischemic heart disease, generalized edema, chronic pain syndrome, tobacco use, neuralgia and neuritis. On the quarterly minimum data set assessment with assessment reference date 10/4/2018, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium or psychosis, and with verbal behavior directed toward others on 1-3 of the 7 days prior to the assessment. The resident required extensive assistance of two staff for bed mobility and transfers and was totally dependent for locomotion on and off the nursing unit.…

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 staff interview, clinical record review and facility document review the facility staff failed to ensure a complete and accurate DDNR (Durable Do Not Resuscitate) for 4 of 39 residents in the survey sample (Residents #14, #72, #55 and #209). The findings included: 1. For resident #14, facility staff failed to obtain a written advance directive prior to initiating a no cardiopulmonary resuscitation order. Resident #14 was admitted to the facility on [DATE]. Diagnoses included anemia, heart failure, hypertension, peripheral vascular disease, atrial fibrillation, edema, arthropathy, and gastroesophageal reflux. On the quarterly minimum data set assessment with assessment reference date [DATE], the resident scored 9/15 on the brief interview for mental status and was assessed as without signs of delirium or psychosis. The resident exhibited behavioral symptoms not directed toward others on 4-6 of the 7 days prior to the assessment. During clinical record review on [DATE], the surveyor noted a 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 observation, staff interview, facility document review and clinical record review, the facility staff failed to provide privacy for 1 of 39 residents during wound care (Resident #18). The findings included: Privacy was not provided during Resident #18's wound care on 10/31/18 by the wound care registered nurse and the restorative certified nursing assistant #1. Resident #18 was admitted to the facility 11/12/14 with diagnoses, that included but not limited to peripheral vascular disease, cellulitis, chronic venous hypertension with ulcer of left lower extremity, major depressive disorder, obesity, type 2 diabetes mellitus, hypertension, hypothyroidism, and edema. Resident #18's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/16/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #18's current comprehensive care plan dated 2/4/18 identified the resident to be at risk for skin breakdown per Braden scale-13. Interventions included to perform wound care as ordered. Resident #18's physician orders 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, staff interview and clinical record review, the facility staff failed to provide clean privacy curtains in 2 of 39 residents rooms (Resident #18 and Resident #192). The findings included: 1. The facility staff failed to ensure the privacy curtains in Resident #18's room were clean. Resident #18 was admitted to the facility 11/12/14 with diagnoses, that included but not limited to peripheral vascular disease, cellulitis, chronic venous hypertension with ulcer of left lower extremity, major depressive disorder, obesity, type 2 diabetes mellitus, hypertension, hypothyroidism, and edema. Resident #18's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/16/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #18's current comprehensive care plan dated 2/4/18 identified the resident to be at risk for skin breakdown per Braden scale-13. Interventions included to perform wound care as ordered. Resident #18's physician orders…

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 resident interview, staff interview, and clinical record review, facility staff failed to provide care for the resident's right to choose activities and associates within the community for 1 of 39 residents in the survey sample (Resident #263). Resident #263 was admitted to the facility on [DATE]. Diagnoses included hypertension, obstructive uropathy, cerebrovascular accident, non-Alzheimer's dementia, hemiparesis, depression, spinal stenosis, chronic ischemic heart disease, generalized edema, chronic pain syndrome, tobacco use, neuralgia and neuritis. On the quarterly minimum data set assessment with assessment reference date 10/4/2018, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium or psychosis, and with verbal behavior directed toward others on 1-3 of the 7 days prior to the assessment. The resident required extensive assistance of two staff for bed mobility and transfers and was totally dependent for locomotion on and off the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, family interview, and staff interview, facility staff failed to develop a person center care plan to assist the resident in participating in his preferred social activity for 1of 39 residents in the survey sample (Resident #263). Resident #263 was admitted to the facility on [DATE]. Diagnoses included hypertension, obstructive uropathy, cerebrovascular accident, non-Alzheimer's dementia, hemiparesis, depression, spinal stenosis, chronic ischemic heart disease, generalized edema, chronic pain syndrome, tobacco use, neuralgia and neuritis. On the quarterly minimum data set assessment with assessment reference date 10/4/2018, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium or psychosis, and with verbal behavior directed toward others on 1-3 of the 7 days prior to the assessment. The resident required extensive assistance of two staff for bed mobility and transfers and was totally dependent for locomotion on and off 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 resident interview, family interview, and staff interview, facility staff failed to revise the care plan to accommodate the resident in participating in his preferred social activity for 1 out of 39 residents in the survey sample (Resident #263). Resident #263 was admitted to the facility on [DATE]. Diagnoses included hypertension, obstructive uropathy, cerebrovascular accident, non-Alzheimer's dementia, hemiparesis, depression, spinal stenosis, chronic ischemic heart disease, generalized edema, chronic pain syndrome, tobacco use, neuralgia and neuritis. On the quarterly minimum data set assessment with assessment reference date 10/4/2018, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium or psychosis, and with verbal behavior directed toward others on 1-3 of the 7 days prior to the assessment. The resident required extensive assistance of two staff for bed mobility and transfers and was totally dependent for locomotion on and off 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 resident interview, staff interview, and clinical record review, facility staff failed to provide for the resident's right to choose activities or provide alternatives to preferred activities for 1 of 39 residents in the survey sample (Resident #263). Resident #263 was admitted to the facility on [DATE]. Diagnoses included hypertension, obstructive uropathy, cerebrovascular accident, non-Alzheimer's dementia, hemiparesis, depression, spinal stenosis, chronic ischemic heart disease, generalized edema, chronic pain syndrome, tobacco use, neuralgia and neuritis. On the quarterly minimum data set assessment with assessment reference date 10/4/2018, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium or psychosis, and with verbal behavior directed toward others on 1-3 of the 7 days prior to the assessment. The resident required extensive assistance of two staff for bed mobility and transfers and was totally dependent for locomotion on and off 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, staff interview and clinical record review, the facility staff failed to provide treatment to prevent pressure ulcers for 1 of 39 residents (Resident #106). The findings included: The facility staff failed to float Resident #106's heels with air boots while in bed prn (as needed). The clinical record of Resident #106 was reviewed 10/30/18 through 11/2/18. Resident #106 was admitted to the facility 9/6/14 with diagnoses that included but not limited to end stage renal disease, chronic kidney disease (stage 4), hypertension, seizures, atrial fibrillation, cerebrovascular disease, gastro-esophageal reflux disease, gout, anemia, urine retention, dysphagia, benign prostate hyperplasia, hypokalemia, thrombocytopenia, gastrostomy status, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hyperlipidemia. Resident #106's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/27/18 assessed the resident with a brief interview for mental status (BIMS) as 00. Resident #106 was determined to be at risk for pressure ulcers…

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, staff interview, clinical record review, and facility document review, the facility staff failed to provide services to prevent urinary tract infections for 2 of 39 Residents in the survey sample, Resident # 213 and Resident # 235. The findings included: 1. The facility staff failed to ensure that Resident # 213 had the correct size Foley catheter per physician's orders. Resident # 213 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to: neuromuscular dysfunction of bladder, heart failure, retention of urine, and chronic pain. The clinical record for Resident # 213 was reviewed on 10/31/18 at 3:57 pm. The most recent MDS assessment (minimum data set) was a 30-day scheduled assessment with an ARD (assessment reference date) of 10/15/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 213 had a BIMS score (brief interview for mental status) of 15 out of 15, which…

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 and clinical record review, the facility staff failed to administer oxygen as ordered by the physician and failed to maintain nebulizer equipment for 2 of 39 residents in the survey sample (Resident #55 and Resident #108). 1. The facility staff failed to administer oxygen as ordered by the physician for Resident #55. Resident #55 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to atrial fibrillation, coronary heart failure, peripheral vascular disease, dementia, depression and left below the knee amputation. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/4/18 the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 8 out of a possible score of 15. Resident #55 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. During the initial tour of the facility on 10/30/18 at 1:15…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility document review and staff interview, the facility staff failed to follow infection control guidelines during the wound observation for 2 of 39 residents in the survey sample and during the medication administration observation (Resident #55, Resident #285). 1. The facility staff failed to follow infection control guidelines during the wound care observation for Resident #55. Resident #55 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to atrial fibrillation, coronary heart failure, peripheral vascular disease, dementia, depression and left below the knee amputation. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/4/18 the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 8 out of a possible score of 15. Resident #55 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member 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.