Centerville Health and Rehab

Inspectors wroteBased on medical record review, staff interviews, resident interview, and policy interview, the facility failed to provide timely dental services for residents to obtain dentures. This affected one (Resident #43) of five residents sampled for dental services. The facility census was 81.

Inspectors wroteBased on medical record review, observations, staff interview, and policy review, the facility failed to maintain professional standards of infection control during medication administration. This affected two (Residents #3 and #6) of three residents sampled for medication administration. The facility census was 81.

Inspectors wroteBased on record review, observations, staff and resident interviews and policy review, the facility failed to provide a private space for phone conversations without being overheard. This affected one (#80) out of three residents reviewed for reasonable access to privacy. The facility census was 78.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure weekly skin assessments were conducted as scheduled for skin integrity monitoring. This affected one (#85) of three residents reviewed for preventative skin interventions. The facility census was 78.

Inspectors wroteBased on record review and staff interview, the facility failed to obtain laboratory tests as ordered. This affected one (#85) of three residents reviewed for laboratory services. The facility census was 78.

Inspectors wroteBased on observation, interview, facility document review, and policy review, the facility failed to maintain the food prep areas in a sanitary manner, failed to ensure proper setup of the three-compartment sink; and failed to complete daily temperature logs for the dish machine. This affected all residents who received food from the kitchen. The facility census was 84.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure medications and opened insulin vials were discarded when expired in two (Roosevelt, [NAME]) of four medication carts observed. The facility census was 84.

Inspectors wroteBased on observation, record review, interview, and review of manufacturer's guidelines, the facility failed to obtain laboratory tests as ordered by the physician for one (Resident #10) of five residents reviewed for unnecessary medications. Additionally, the facility failed to ensure expired blood glucose monitoring strips were discarded in four (Roosevelt, [NAME], [NAME], Jefferson) four medication cars observed. The facility census was 84.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN, Form CMS-10055) was prior to the end of covered Medicare Part A services for one (Resident #43) of three sampled residents reviewed for beneficiary notifications. The census was 84.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure broken bathroom sink faucets in resident rooms, loose door handles to resident rooms, and missing tiles outside the therapy room were repaired to provide a homelike environment. This affected four resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on two of six halls and the public hallway outside the therapy room. The facility census was 84.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to prevent staff verbal abuse for two (Resident #25 and Resident #66) of three residents reviewed for abuse. The facility census was 84.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to report allegations of abuse to the administrator and the state survey agency for two (Resident #25 and Resident #66) of three residents reviewed for abuse. The census was 84.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure allegations of abuse were investigated and failed to prevent further abuse by removing the emoployee from duty after an allegation of abuse. This affected two (Resident #25 and Resident #66) of three residents reviewed for abuse. The facility census was 84.

Inspectors wroteBased on interview, record review, and a review of the facility's policy, the facility failed to notify the Office of the State Long Term Care Ombudsman and failed to provide written bed-hold notices for two (Resident #22 and Resident #17) of two residents reviewed for hospitalization.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to revise a care plan for one (Resident #19) of one resident reviewed for tube feedings. The facility census was 84.

Inspectors wroteBased on observations, record review, staff, and resident interviews, and review of facility policy, the facility failed to ensure a clean, safe, comfortable environment for all residents. This affected 11 (#02, #06, #19, #31, #32, #35, #38, #44, #53, #70, and #71) residents who resided in the facility. The facility census was 77.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure the facility was free from pests. This affected one (#26) of four residents reviewed for effective pest control. The facility census was 78.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure the facility was free from pests. This had potential to affect all 81 facility residents. The census was 81.

Inspectors wroteBased on observations, staff and resident interviews, interview with the Pest Control Representative, review of pest control notes, and review of facility policy, the facility failed to maintain the kitchen and dining room area free from pests. This had potential to affect all 74 facility residents.

Inspectors wroteBased on observations, staff interview, and resident interviews, facility failed to ensure resident rooms were maintained in clean, working order. This affected three (#23, #46, and #50) of three residents reviewed for environment. The facility census was 74.

Inspectors wroteBased on observations, review of the facility pest control invoices, and staff and resident interviews, the facility failed to ensure effective pest control measures were in place. This had the potential to affect all 69 residents residing in the facility. The facility census was 69.

Inspectors wroteBased on medical record review, observation, staff and resident interviews, and policy review, the facility failed to provide care and services to ensure fingernails were trimmed and free of dirt and debris. This affected one (#30) out of three residents reviewed for Activities of Daily Living (ADL's). The facility census was 69.

Inspectors wroteBased on medical record reviews, staff and resident interviews, and policy review, the facility failed to ensure splints/braces were applied as ordered. This affected two (#30 and #75) out of three residents reviewed for cares and services to prevent decline in range of motion (ROM). The facility census was 69.

Inspectors wroteBased on the medical record reviews, observations, staff and resident interviews, and policy review, the facility failed to ensure medications were administered as ordered resulting in two medications errors out of 28 opportunities or a 7.14 percent (%) medication error rate. This affected two (#50 and #62) out of three residents reviewed for medication administration. The facility census was 69.

Inspectors wroteBased on observations, staff interviews, review of infection control logs, review of dishwasher logs and review of service invoices, the facility failed to ensure the dishwashing machine had the appropriate rinse temperature and chemicals to sanitize dishes. This had the potential to affect all 60 residents who receive food from the kitchen. The facility census was 60.

Inspectors wroteBased on medical record review, observations, staff interview, facility policy review and review of information from the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS), the facility failed to implement infection control practices by ensuring staff wore appropriate personal protective equipment (PPE) to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 60 residents residing at the facility. The facility census was 60.

Inspectors wrote4. Review of Resident #43's medical record revealed the resident was admitted on [DATE] with a readmission on [DATE] from a hospital stay from 01/18/22 through 01/20/22. Diagnoses include epilepsy and seizures. Further medical record review for Resident #43 revealed there was no documented evidence the Ombudsman was notified of the hospital transfer. Interview on 04/13/22 at 11:38 A.M. with the Social Service Director (SSD) #22 revealed she has not notified the Ombudsman of discharges from the facility because the facility was given a new Ombudsman and she was waiting for them to give her their email address. SSD #22 confirmed there was no evidence of the Ombudsman being notified of Resident #14, #28, #43 or #61's transfers to the hospital. Interview on 04/13/22 at 1:28 P.M. [...]

Inspectors wrote2. Review of Resident #28's medical record revealed she was admitted on [DATE]. Diagnoses included but not limited to repeated falls, lack of coordination, type 2 diabetes mellitus without complications, altered mental, major depressive disorder recurrent, and chronic obstructive pulmonary disease. Resident #28 is her own responsible person. Review of the MDS assessment dated [DATE] revealed Resident #28 to have intact cognition and required extensive assistance with one person physical assist for Activities of Daily Living, (ADL's). Record review of the electronic medical record revealed Resident #28 was discharged to the hospital on [DATE] via emergency medical transport. Further medical record review for Resident #28 revealed there was no documented evidence the resident received the bed hold notice. [...]

Inspectors wroteBased on medical record review, observation and staff and resident interview, the facility failed to ensure a resident was afforded with the choice of personal care for showering/bathing. This affected one (#53) out of three residents reviewed for choices. The facility census was 60.

Inspectors wroteBased on medical record review, staff interviews, review of facility self-reported incidents and policy review, the facility failed to report an allegation of sexual abuse to the state survey agency. This affected one (#5) of three residents reviewed for abuse. The census was 60. Findings Include: Review of Resident #1's medical record revealed an admission date of 08/27/18 and a readmission date of 04/01/22. Diagnoses included dementia, psychosis, and lung disease. The most recent quarterly Minimum Date Set (MD'S) dated 03/22/22 revealed the resident was severely cognitively impaired and required assistance of one with all care. The resident requires limited assist with ambulation. Review of the behavior plan of care dated 10/05/21 revealed the resident was sexually inappropriate by comments and request. [...]

Inspectors wroteBased on medical record review, staff interviews, review of facility self-reported incidents and policy review, the facility failed to investigate an allegation of sexual abuse. This affected one (#5) of three residents reviewed for abuse. The census was 60. Findings Include: Review of Resident #1's medical record revealed an admission date of 08/27/18 and a readmission date of 04/01/22. Diagnoses included dementia, psychosis, and lung disease. The most recent quarterly Minimum Date Set (MD'S) dated 03/22/22 revealed the resident was severely cognitively impaired and required assistance of one with all care. The resident requires limited assist with ambulation. Review of the behavior plan of care dated 10/05/21 revealed the resident was sexually inappropriate by comments and request. Interventions included diversional activity, redirect, refer to psychiatrist as needed. [...]

Inspectors wroteBased on medical records and staff and resident interviews, the facility failed to ensure residents were invited to care conferences to allow them to provide input in their care. This affected two (#28 and #42) out of three residents reviewed for care conferences participation. Facility census was 60.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure care planned interventions were in place for prevention of falls/accidents. This affected one (#31) of three residents reviewed for falls. The facility census was 60.

Inspectors wroteBased on medical record review, observations and staff and resident interviews, the facility failed to ensure dialysis resident received meals before dialysis appointments. This affected one (#48) of one residents reviewed for dialysis. Facility census was 60.

Inspectors wroteBased on medical record review, observations and staff and resident interviews, the facility failed to ensure an assessment was completed regarding the use of bedrail's on a residents bed. This affected one (#14) out of three residents reviewed for the use of bedrail's. The facility census was 60.

Inspectors wroteBased on personnel file review and staff interview, the facility failed to provide performance evaluations for state tested nursing assistants (STNA's). This affected one of five state tested nursing assistant employee files reviewed and had the potential to affect all 60 residents residing in the facility. Facility census was 60.

Inspectors wroteBased on review of personnel files and staff interview the facility failed to provide State Tested Nursing Assistant (STNA) annual performance reviews. This affected three STNA's (#9, #99 and #115) of three STNAs who worked at the facility longer than a year. This had the potential to affect all the residents at the facility. The facility census was 103.

Inspectors wroteBased on observation, staff interview, and review of manufacture's directions, the facility failed to ensure that mobile and stationary food preparation equipment was properly sanitized, and nutritional supplements and thickened liquids stored in unit refrigerators were stored in a manner to ensure that resident's were not served outdated/spoiled supplements and thickened liquids. This had the potential to affect all 103 residents of the facility.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure each resident was treated in a manner and environment that promoted their individuality and dignity during dining. This had the potential to affect all 15 residents (#3, #4, #5, #21, #25, #40, #51, #55, #56, #57, #62, #81, #90, #93, and #100) of the secured 400/[NAME] unit. The facility census was 103.

Inspectors wroteBased on observation and staff interview, the facility failed to provide necessary maintenance and housekeeping services to maintain a sanitary, orderly, and comfortable interior. This involved 15 of 15 residents (#3, #4, #5, #21, #25, #40, #51, #55, #56, #57, #62, #81, #90, #93, and #100) who resided on the secured 400/[NAME] unit . The facility census was 103.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure the residents or the Ombudsman were provided with a written notice of the reason for discharge or transfer. This affected five (#12, #50, #58, #64 and #302) of six residents reviewed for discharge notification. The facility census was 103.

Inspectors wroteBased on medical record review, resident and staff interview, and review of facility policy, the facility failed to timely provide written bed-hold notices to residents when hospitalized . This affected four (#12 #50, #58 and #302) of six residents reviewed for hospitalizations. The facility census was 103.

Inspectors wroteBased on observation, staff interview, and review of activity calendar, the facility failed to provide an ongoing program of activities for each resident that met their individual needs and preferences. This directly affected two resident (#55, #81) and had the potential to affect all 15 residents (#3, #4, #5, #21, #25, #40, #51, #55, #56, #57, #62, #81, #90, #93, and #100) of the secured 400/[NAME] unit for resident's with dementia related diagnoses. The facility census was 103.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident's Do No Resuscitate (DNR) code status designation was documented on a valid form and failed to ensure resident's code status matched throughout the medical record. This affected two (#10 and #50) of 32 residents reviewed during the initial pool screening of the annual survey. The facility census was 103.

Inspectors wroteBased on medical record review and interview the facility failed to ensure residents that were discharged from Medicare Part A services were notified of the potential liability for payment. This affected two (#79 and #306) of three residents reviewed for beneficiary notices. The facility census was 103.

Inspectors wroteBased on medical record review, resident and staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to ensure resident's Minimum Data Set (MDS) assessments were completed accurately for required Preadmission Screening and for discharge planning. This affected two residents (#39 and #58) of 32 reviewed during the annual survey. The facility census was 103.

Inspectors wroteBased on record review, and staff interviews, the facility failed to accurately complete pre-admission screening and resident review (PASARR) for newly admitted residents. The facility also failed to notify the state mental health authority of significant changes in a resident's mental health. This affected three (#37, #58, and #99) of three residents reviewed for PASARR. The facility census was 103.

Inspectors wroteBased on record review and staff interview, the facility failed to develop accurate baseline care plans for residents within 48 hours of their admission. This affected two (#10 and #27) of 23 residents reviewed for baseline care plans. The facility census was 103.

Inspectors wroteBased on medical record review, observation, staff interview, review of activity schedules and participation records, the facility failed to develop and implement a comprehensive person-centered plan of care for activities for two residents (#55 and #81) and develop a comprehensive plan of care regarding anticoagulation use and dementia care for one resident (#27). The deficit practice affected three residents (#27, #55, and #81) of 26 care plans reviewed during the investigative phase. The facility census was 103.

Inspectors wroteBased on medical record review, and resident and staff interview, the facility failed to ensure residents' discharge goals were included in the comprehensive care plan. This affected one (#39) of three residents reviewed for discharge planning. The facility census was 103.

Inspectors wroteBased on medical record review, observation, and staff interview the facility failed to provide dependent residents with the necessary personal care consistent with needs and preferences. This involved one resident (#7) of three reviewed for Activities of Daily Living (ADL). The facility census was 103.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident had a physician's order to discharge from the facility. This affected one (#102) of 23 residents reviewed for physician's orders. The facility census was 103.

Inspectors wroteBased on medical record review, pharmacy recommendation review, and staff interview, the facility failed to ensure psychotropic medications ordered on an as needed basis were not ordered for an indefinite period of time. This affected one (#75) of five residents reviewed for unnecessary medications. The census was 103.

Inspectors wroteBased on medical record review, observation, staff interview and review of facility policy the facility failed to appropriately label opened bottles of eye medications. This directly affected one resident (#252) during observation. The facility reported 29 residents received eye drops in the facility. The facility also failed to ensure medications were secure. This affected one resident (#64) of three residents reviewed for medication administration. The facility census was 103.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure each resident received their mechanically altered therapeutic diets as ordered by the physician. This involved one resident (#55) of 15 residents observed during dining who resided on the secured 400 unit ([NAME] Unit). The facility census was 103.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Administrator was present at quarterly quality assessment and assurance (QAA) meetings. This had the potential to affect all the residents in the facility. The facility census was 103.