Altercare of Navarre Ctr for Rehab & Nrsg Care

Inspectors wroteBased on review of the medical record and interview, the facility failed to ensure laboratory tests for urine culture and sensitivity were obtained timely and as ordered for Resident #90. This effected one resident (#90) of three reviewed for bowel and bladder. The facility census was 91. Findings Include: Review of the medical record revealed Resident #90 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to provide sufficient nursing staff to meet resident needs including answering call lights in a timely manner and operating mechanical lift devices in a safe manner. This affected three residents (#17, #40, and #61) and had the potential to affect all 89 residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician or nurse practitioner (NP) was notified promptly of Resident #104's change in condition, failed to ensure Residents #7 and #52's wound care were completed as ordered and Resident #98's peripherally inserted central catheter (PICC) was removed timely as ordered. This finding affected one (Resident #104) of three residents reviewed for a change in condition, two (Residents #7 and #52) of three residents reviewed for general skin conditions, and one (Resident #98) of one resident reviewed for PICC lines. The facility census was 89.

Inspectors wroteBased on record review and interview, the facility failed to obtain Residents #3, #84, #101 and #104's weights as ordered to ensure proper nutrition status. This finding affected four residents (Residents #3, #84, #101 and #104) of six residents reviewed for nutrition. The facility census was 89.

Inspectors wroteBased on record review and interview, the facility failed to maintain complete and accurate documentation in the medical record for all residents. This affected five residents (#2, #8, #26, #57, and #86) and had the potential to affect all 89 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #54's dignity was maintained at all times. This affected one resident (Resident #54) of three residents reviewed for dignity. The facility census was 86. Review of the medical record for Resident #54 revealed an admission date of 07/03/25 with diagnoses included hypertension, atrial fibrillation, and legal blindness. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. Resident #54 required extensive assistance for all activities of daily living. Review of the physician's order dated 07/17/25 revealed Resident #54 was dependent for shaving and required shaving weekly. Review of the care plan dated 01/19/26 revealed Resident #54 was unable to perform activities of daily living. [...]

Inspectors wroteBased on interview and record review the facility failed to notify Resident #98's representative of a change in condition. This affected one (Resident #98) of three residents reviewed for notification of change in condition. The facility census was 86.

Inspectors wroteBased on interview and record review the facility failed to care plan a peripherally inserted central catheter (PICC) line for Resident #98. This affected one resident (Resident #98) of six residents reviewed for care plans. The facility census was 86. Review of the medical record for Resident #98 revealed an admission date of 01/19/26 and discharge date of 02/10/26 with diagnoses included metabolic encephalopathy, chronic diastolic heart failure, peripheral vascular disease, and end stage renal disease. Review of the orders for Resident #98 revealed an order dated 01/27/26 revealed an order to schedule an appointment for PICC line removal. No other PICC line orders were observed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #98 had mild cognitive impairment and required extensive assistance for all activities of daily living. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were revised for weight loss. This affected two residents (Residents #84 and #101) of six residents reviewed for nutrition. The facility census was 89. Findings Include:1. Resident #84 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, traumatic brain injury, legal blindness, overactive bladder, psychosis, visual hallucinations, delusional disorder, anxiety disorder, epilepsy, chronic pain, and major depressive disorder. Review of Resident #84's nursing progress notes revealed on 04/04/26 at 2:17 P.M. Registered Dietician (RD) #650 documented the resident had a significant weight loss at the 180 day marker with March weights. Weight loss was appropriate due to her Body Mass Index (BMI) of 25.3 being overweight for her height. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed timely assist Resident #17 with activities of daily living (ADLs). This affected one resident (Resident #17) out of 13 reviewed for ADL care. The facility census was 89.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #3, #66 and #67's pressure ulcer wound care was completed as ordered and per best practice guidelines. This finding affected three (Residents #3, #66 and #67) of six residents reviewed for pressure ulcers. The facility census was 89.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to provide safe transfer assistance utilizing a mechanical lift device for Resident #61. This affected one resident (#61) out of seven reviewed for accident hazards. The facility census was 89.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to ensure Resident #27's respiratory needs were ordered and the cleaning and storage of oxygen services were in place. This affected two residents (#27 and #89) out of four reviewed for respiratory care. The facility census was 89.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents on dialysis received ongoing assessment and monitoring to ensure health status and reduce complication of dialysis care. This finding affected three (Residents #26, #67, and #85) of five residents reviewed for dialysis. The facility census was 89.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #12 was free from significant medication error. This finding affected one (Resident #12) of six residents observed for medication administration. The facility census was 89.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were secured appropriately. This finding affected two of the three medication carts reviewed. The facility census was 89.

Inspectors wroteBased on record review and interview, the facility failed to obtain laboratory samples and results as ordered. This affected one resident (#85) out of six reviewed for unnecessary medications. The facility census was 89.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to ensure staff followed infection control protocols for residents on contact isolation and droplet isolation. This affected three residents (#12, #17, and #40) out of five reviewed for infection control. The facility census was 89.

Inspectors wroteBased on medical record review, review of hospital documentation, policy review, and interview, the facility failed to ensure ongoing assessments and monitoring were completed for Resident #10's right ring finger skin impairment. This finding affected one (Resident #10) of three residents reviewed for skin impairments. Actual harm occurred on 07/02/25 when Resident #10, who was assessed upon admission with a right ring finger bruise and/or scab, was admitted to the hospital with the diagnosis of a necrotic finger resulting in the partial amputation of his right ring finger. Findings Include:Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses including necrotizing fasciitis, cutaneous abscess of the groin and end stage renal disease. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #8's responsible party was notified of new orders and changes in Resident #8's condition. This affected one (Resident #8) of three residents reviewed for notifications. The facility census was 83.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview and policy review the facility failed to prevent Resident #8 from receiving the wrong medication. This affected one (Resident #8) of three residents reviewed for medications. The facility census was 83.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure wound care was completed as ordered for Residents #43, #51 and #77 and timely wound assessments were completed for Resident #77. This finding affected three (Residents #43, #51 and #77) of four residents reviewed for wounds.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #77's pressure ulcer wound care was completed as ordered. This finding affected one (Resident #77) of four residents reviewed for wound care.

Inspectors wroteBased on observation, review of resident diet orders, review of menus/spreadsheets, and interview, the facility failed to ensure proper portion sizes of food were served to residents on a carbohydrate controlled (CCHO)/low concentrated sweet (LCS) diet. This affected six (Residents #32, #35, #36, #39, #40, and #43) of 30 residents on the 200 hall who had trays served.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to monitor a resident's oxygen saturations in accordance with physician orders. This affected one (Resident #44) of three residents reviewed for respiratory care. The census was 87.

Inspectors wroteBased on resident medical record review, observation and staff interview the facility failed to ensure pressure ulcer wounds were accurately staged. This affected two (Residents #47 and #39) of five residents reviewed for pressure ulcers. The facility identified six residents (Residents #5, #8, #39, #47, #53 and #245) with current pressure ulcer wounds.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #30's expired Lantus long-acting insulin was discarded as appropriate. This finding affected one (Resident #30) of two residents who receive insulin on the 100 A medication cart.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure appropriate infection control procedures were maintained while completing Resident #193's wound care. This finding affected one (Resident #193) of five residents reviewed for pressure wounds.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, investigation review and policy review the facility failed to prevent misappropriation of resident medication. This affected three residents (#10, #11 and #12) of three residents reviewed for misappropriation. The census was 86.

Inspectors wroteBased on review of receipts, observations, and interviews, the facility failed to provide an adequate supply of supports for daily living. This affected two residents (#19 and #16) of three residents reviewed for incontinence care. This had the potential to affect 37 residents in the facility who are dependent on staff for the provision of incontinence care.

Inspectors wroteBased on medical record review, review of resident Matrix, policy review, and interviews the facility failed to ensure wound care was provided per orders. This affected one resident (#70) of three reviewed for skin alterations.

Inspectors wroteBased on record review, policy review, review of the skill competency form for catheter care, observation, and interviews the facility failed to ensure infection control practices were maintained during urinary catheter care. This affected one resident (#24) of one resident observed for urinary catheter care.

Inspectors wroteBased on medical record review, review of Center of Disease Control (CDC) information and guidance, review of infection control log, review of email, policy review, observation, and interviews the facility failed to ensure isolation protocols were discontinued timely. This affected three residents (#10, #63, and #70) of four residents reviewed for isolation.

Inspectors wroteBased on review of pictures, observation, and interviews the facility failed to ensure a safe path of egress on the 300 hall. This had the potential to affect 27 residents (#8, #14, #15, #18, #19, #29, #34, #38, #39, #46, #50, #52, #55, #59, #60, #62, #70, #71, #74, #82, #85, #86, #87, #89, #91, #94, and #100) of 106 residents residing in-house during the time of the survey.

Inspectors wroteBased on closed medical record review, hospital record review and staff interview the facility failed to implement a comprehensive and individualized pressure ulcer prevention program for Resident #95 to prevent the development and worsening of pressure ulcers. Actual harm occurred on [DATE] when Resident #95 was admitted to the facility, at risk for pressure ulcer development and with evidence of pressure ulcers present and was not provided adequate assessment/monitoring of skin, wound care or effective and individualized pressure ulcer preventative measures. [...]

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure proper storage of food items. This had the potential to affect all residents receiving food items from the facility kitchen. The facility identified one resident (Resident #5) who did not receive any food items from the facility kitchen. The facility census was 97.

Inspectors wroteBased on observation, record review, interview, and policy review the facility failed to ensure meal tickets accurately reflected renal diets and residents who were ordered renal diets received meals as ordered. This finding affected three (Resident's #15, #59 and #75) of four residents reviewed for renal diets. The facility census was 97.

Inspectors wroteBased on observation, interview, and policy review the facility failed to store opened medications per facility protocol in three of four medication carts reviewed for medication storage. This affected six (Resident's #21, #36, #11, #26, #73, and #60) residents and had the potential to affect all 97 residents residing in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure Resident #353's wound care was completed as ordered. This finding affected one (Resident #353) of three residents reviewed for general skin conditions. The facility census was 97.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #75's pressure ulcer wound care was completed as ordered. This finding affected one (Resident #75) of three residents reviewed for pressure ulcer wound care. The facility census was 97.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview the facility failed to ensure restorative range of motion and splint devices were implemented as ordered by the physician for residents identified with contractures of joints. This affected one (Resident #49) of one resident reviewed for joint limitation. The facility census was 97.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure one (Resident #69) received tube feeding that was not expired of one resident reviewed for tube feeding. The facility census was 97.

Inspectors wroteBased on record review, review of the facility infection control logs, review of facility policy and procedure, and staff interview the facility failed to implement an effective antibiotic stewardship program to ensure antibiotics were not used unless residents met the criteria to treat an infection. This affected three residents (Resident's #10, #33, and #35) of five residents reviewed for antibiotic stewardship. This had the potential to affect all 97 residents in the facility.