Custer Care and Rehab Center

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure that a resident's advance directive (a legal document that expresses a person's health care wishes if they become unable to speak for themselves) and code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) were accurately documented to reflect the resident's chosen wishes for one of one sampled resident (16) with documented code status discrepancies.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure standard infection control practices were followed for the cleaning of one of one water and ice dispenser located in a passthrough room between the 200 and 400 hallway.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure:*The resident or the resident's representative was given a bed hold notice for five of five sampled residents (6, 7, 8, 26, and 30) who transferred to the hospital. *The ombudsman was notified of resident transfers to the hospital for three of five sampled residents (6, 26, and 30) who transferred to the hospital.

Inspectors wroteBased on Payroll Based Journal (PBJ) CASPER (Certification and Survey Provider Enhanced Reporting) reports, interview, and record review, the provider failed to ensure the PBJ data was submitted accurately to the Centers for Medicaid and Medicare Services (CMS) for Federal Fiscal Quarter 2 (Q2) (January, February, and March 2025).

Inspectors wroteBased on Payroll Based Journal (PBJ) CASPER (Certification and Survey Provider Enhanced Reporting) reports, interview, and record review, the provider failed to ensure the PBJ data was submitted accurately to the Centers for Medicaid and Medicare Services (CMS) for Federal Fiscal Quarter 2 (Q2) (January, February, and March 2025).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to maintain an effective, ongoing quality assurance and performance improvement (QAPI) program regarding quality of care and outcomes to ensure:*A performance improvement plan (PIP) was implemented, actions were taken, and improvements were evaluated for the high-risk and problem-prone areas identified. This included the 14-day as needed psychotropic medication stop dates, missing consent forms, and the assessment tools used to monitor adverse side effects in residents taking psychotropic medications.*Governing board member oversight of the facility's QAPI program.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure infection control practices and facility policies were followed regarding the assessment for the risk of Legionella (bacteria that can grow in water and cause serious illness), the implementation of measures to prevent the growth of Legionella, and the establishment of testing protocols for Legionella.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure that two of two sampled residents (6 and 7), who experienced two or more areas of decline from their baseline conditions, had a significant change in status assessments completed related to fractures that resulted from their falls.

Inspectors wroteBased on observation, interview, record review, Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1 October 2024 review, the provider failed to ensure two of two sampled residents' (3 and 4) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments were accurately coded for the area of restraints.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the resident or the resident's representative was involved in the development of a baseline care plan and given a copy of that care plan within 48 hours of admission for four of four sampled residents (1, 7, 21, and 26) reviewed.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the resident's care plan was reviewed and revised to reflect the current necessary care needs for six of six sampled residents (5, 6, 12, 21, and 26).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure:*Psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) ordered to be given as needed were not discontinued after 14 days, and did not have a rationale documented for continued use for four of nine sampled residents (7, 13, 21, and 30) reviewed with physician's orders for psychotropic medications.*Abnormal Involuntary Movement Scale (AIMS) (an assessment to identify the severity of involuntary movements in residents taking neuroleptic medications) assessments were routinely completed to evaluate for signs of adverse effects for eight of nine sampled residents (1, 6, 7, 13, 18, 21, 23, and 30) reviewed with physician's orders for psychotropic medications.*Consent forms for the use of psychotropic medications were obtained for nine of nine sampled [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure:*MD C fulfilled his role and responsibilities to assist according to the provider's medical director physician agreement to provide guidance in developing and implementing patient care policies and the duties as a member of the QAA/AQPI committee, including evaluating and guiding other committee members on corrective plans for high-risk or problem-prone areas identified.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to maintain an effective quality assessment and assurance (QAA) committee that ensured:*Medical director (MD) C, regional director (RD) T, business office manager (BOM) H, consultant pharmacist D, dietary manager (DM) U, and maintenance manager (MM) G attended the QAA/QAPI meetings at least quarterly as members of the QAA committee. *There was evidence that MD C had assisted with the development, coordination, review, and acknowledgement of the facility's QAA/QAPI policies and procedures and program overview.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled residents (6) had a Level II Preadmission Screening and Resident Review (PASRR) screening (a federally mandated program that requires all individuals applying for admission to or currently residing in a Medicaid-certified nursing facility to be screened to determine if they have a serious mental illness, intellectual disability, or developmental disability. Level I screening is conducted to identify if individual has a PASRR condition; if positive, a comprehensive Level II evaluation is performed to determine individual needs, appropriate placement, and services.) completed.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure that a comprehensive care plan was developed within 14 days of their admission for four of four sampled residents (1, 7, 21, and 26) reviewed.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure that three of three sampled residents (3, 5, and 8) who used bed rails/bars attached to the bed had other attempted interventions documented.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure the required daily nurse staffing information, including the total number and actual hours worked by licensed and unlicensed nursing staff, and the resident census was current and posted daily.

Inspectors wroteBased on observation and interview, the provider failed to ensure the bed/side rails for three of three sampled residents (3, 5, and 8) who had side rails on their beds were inspected for safety, including entrapment (being caught between bed system parts) risk, before being placed on the residents' beds and were monitored after installation to ensure they were maintained in safe conditions for use and free of entrapment risks.