Dennett Rehab Center

Inspectors wroteBased on observations, interviews, record reviews, and review of facility investigative records and witness statements, the facility failed to provide adequate supervision and implement appropriate interventions to prevent elopement for 1 of 3 sampled residents (Resident #5) who was identified as being at risk for elopement. As a result, Resident #5 eloped from the facility and was located walking on a main road before being safely returned to the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a nurse followed a physician's order for wound care for 1 (Resident #3) of 3 sampled residents reviewed for wound care.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to employ a qualified kitchen manager and/or a full-time dietician to execute the functions of the food and nutrition service. ServSafe is an accredited food and beverage training and certificate program administered by the US National Restaurant Association. The goal is to prevent foodborne illnesses based on a set of guidelines to improve safety and hygiene in food preparation. To become a Certified Dietary Manger (CDM), one must complete and pass an exam through an accredited program administered by the Association of Nutrition and Foodservice Professionals.

Inspectors wroteBased on interviews, food tray sampling, and observation, it was determined that the facility failed to provide food that was appetizing in temperature, palatability, and flavor. This was evident during random resident interviews and food tray sampling. This had the potential to impact all residents.

Inspectors wroteBased on observation and staff interviews, the facility failed to store and prepare food in accordance with professional standards for food service safety. This was evident by unsanitary conditions and unlabeled food items throughout the kitchen and storage areas observed during the kitchen survey.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to maintain safe operating kitchen equipment. This was evident for the steamer equipment observed during the kitchen survey. On 3/11/26 at 10:04 AM during observation of the kitchen, it was observed that the steamer's on indicator light was dark and that no heat emanated from the steamer. In an interview, the Kitchen Manager (Staff #16) confirmed it hasn't worked for quite a while. She stated that she had verbally reported the broken equipment to the maintenance director. On 3/12/26 at 8:06 AM, during an observation of the kitchen with the Nursing Home Administrator (NHA), it was noted that the on indicator light appeared to be on. In an interview, Staff #16 reported, it doesn't work right. When you open the door hot water spills out. It's not safe. The NHA heard and acknowledged the concern.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure resident dignity was maintained. This was evident for 1 (Resident #74) of 1 Resident observed for dignity.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure a system was in place to review, communicate, and implement pharmacy recommendations following a physician response. This was identified for 5 of 6 residents (#'s 17, 46, 27, 7, 66), reviewed for unnecessary medications.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure resident records were kept private. This was evident when a resident's medical record (Resident #37) was left visible on a computer screen on 1 of 4 nursing stations observed after hours during the survey.

Inspectors wroteBased on record review, observations, and interviews, it was determined that the facility failed to ensure physician orders were implemented. This was evident for 1 (Resident #1) of 5 residents reviewed for accidents during the survey.

Inspectors wroteBased on observation, staff interviews, and record review it was determined that the facility failed to establish systems to accurately reconcile controlled medications using acceptable standards of practice. During observation of the facility narcotic books, it was observed that 2 of 3 narcotic count sheets did not accurately reconcile and document narcotic count during the survey.

Inspectors wroteBased on observation, record review, and interview it was determined that the facility failed to ensure medications were secured and accounted for as evidenced by observation of a resident's medications which were left at the resident's bedside. Maintain and secure controlled medications in a separately locked, permanently affixed compartment. This was evident for 1 (Resident #2) during a random observation and 1 out of 3 refrigerators reviewed for medication storage during a surveyThe

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure communication and collaboration on end of life care with the hospice agency. This was evident for 1 (Resident #78) of 1 residents reviewed for hospice and end of life care.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that licensed personnel used proper hand hygiene during medication administration to prevent and minimize the spread of infections. This was evident for two out of three licensed personnel (LPN #23 and LPN #25) observed during the medication administration task. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve the use of Personal Protective Equipment (PPE) such as gown and glove use during high-contact resident care activities.

Inspectors wroteBased on interview, record review, facility policy review, and the American Diabetes Association Guidelines, the facility failed to follow a physician's order for blood glucose monitoring and failed to assess a blood glucose level on an unresponsive resident with a known diagnosis of diabetes mellitus for 1 (Resident #8) of 4 sampled residents reviewed for diabetic management. This failure resulted in harm, as the resident was sent to the hospital unresponsive for a critical blood glucose level of 29.

Inspectors wroteBased on observation, interview, review of facility reported incidents and facility policy, it was determined that the facility failed to treat a vulnerable resident with respect and free from verbal abuse. This was evident during a complaint survey and a random observation of staff and resident interactions (Resident #39).

Inspectors wroteBased on the review of a facility reported incident #MD00214913, #MD00214911 and #MD00213420, medical record review, interview with facility staff and review of facility policies, it was determined that the facility failed to ensure that residents medications were secure, maintained and free from misappropriation. This was evident for 2 of 3 (#1 and #17) residents reviewed for medication misappropriation. This was identified a D of past non-compliance for facility reported incidents MD00214913 and MD00214911 for F602.

Inspectors wroteBased on observation, interviews, record reviews, and policy reviews, the facility failed to follow infection control and prevention guidelines as follows: The facility staff did not don (put on) personal protective equipment (PPE) prior to entering a resident room and providing hands on care. This was evident during the random observation of staff to resident interactions and patient care. This failure had the potential to affect the spread of infections and involved Resident (39)

Inspectors wroteBased on review of a facility reported incident, medical record review, observation and interview, it was determined facility staff failed to prevent residents assessed to be at risk for elopement from eloping from the facility (Resident #202 and #204). This was evident for 2 of 7 residents reviewed for elopement. This resulted in an immediate jeopardy for the residents at risk for elopement on 2/15/23 and again on 2/6/24. After the elopement for both incidents, the facility put a plan in place to ensure that no other residents eloped from the facility. Review of the facility's plan of correction, implemented immediately after the facility gained knowledge of the elopements on 2/15/23 and 2/6/24, resulted in the citation being cited as past noncompliance. [...]

Inspectors wroteBased on review of complaints, interview, and documentation review, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 9 of 21 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency. This deficient practice had the potential to affect all residents.

Inspectors wroteBased on interview, and facility policy review, the facility failed to employ either a full-time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition service department. This failure had the potential to affect all 75 residents who resided in the facility.

Inspectors wroteBased on observation, interview, record review, review of the facility's meal schedule, and facility policy review, the facility failed to have sufficient competent dietary staff to ensure food was prepared in a sanitary environment for one of one kitchen and food was served as scheduled for the main dining room, the Far East dining room, the East dining room and for two of two residents (Resident (R) 16 and R59) reviewed for timeliness of meals in accordance with professional standards for food safety. The lack of competent dietary staff had the potential to affect 74 residents of 75 residents who consumed meals that were prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food stored in the kitchen was labeled, dated, and/or covered, kitchen equipment and kitchen walls were clean, cookies on resident meal trays were covered when delivered from meal delivery carts to resident rooms, and pudding was served from the kitchen's tray line at an internal temperature of 41 degrees Fahrenheit (F.) or below. This had the potential to affect 74 of 75 residents who consumed food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to promote a dignified dining experience by serving food on disposable plates to residents at meals for four of six hallways (100, 200, 600 and 700 Hallways) and failed to serve meals at the same time to residents who were seated at the same dining room table for one of two dining rooms (Far East dining room) for four of 41 sample residents (Resident (R) 31, R27, R28, and R47). This failure had the potential to affect all residents who were served meals prepared in the facility's one of one kitchen.

Inspectors wroteBased on observation, record review, interview, test tray review, and facility policy review, the facility failed to serve food that was palatable for two of six residents (Residents (R) 16, and R59) reviewed for food palatability of 41 sample residents. This had the potential to affect 74 of 75 residents who consumed food that was prepared from the facility's kitchen.

Inspectors wroteBased on observation, medical record review, and interview, the facility staff failed to honor the needs and preferences of a resident. This was evident for 2 (#205, #1) of 41 residents reviewed during an annual/complaint survey.

Inspectors wroteBased on medical record review, facility documentation review, and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff. This was evident for 2 (#213, #202) of 16 facility reported incidents reviewed during an annual/complaint survey.

Inspectors wroteBased on review of facility reported incidents with documentation and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (#213) of 16 facility reported incidents reviewed during an annual and complaint survey.

Inspectors wroteBased on review of a facility reported incident investigation and staff interview, it was determined the facility failed to thoroughly investigate an incident of alleged verbal abuse. This was evident for 1 (#213) of 16 facility reported incidents reviewed during an annual and complaint survey.

Inspectors wroteBased on record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) User Manual Version 3.0, the facility failed to ensure one out of 41 sampled residents (Resident (R) 73) had an accurately coded Minimum Data Set (MDS) discharge assessment. Failure to code the MDS correctly led to an inaccurately coded discharge assessment.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment and services in accordance with professional standards of practice (Resident #203). This was evident for 1 of 41 residents reviewed during an annual/complaint survey.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement a pressure injury intervention per the physician's orders and care plan for a stage two pressure ulcer and did not document treatment was provided for seven days for one of two residents (Resident (R) 3) reviewed for pressure ulcers out of 41 sampled residents. This failure had the potential to result in wound treatment and interventions not provided for the residents.

Inspectors wroteBased on medical record review and interview, the facility staff failed to intervene in a timely manner for a resident with weight loss (Resident #205). This was evident for 1 of 3 residents reviewed for nutrition concerns during an annual survey.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure oxygen tubing and nasal cannula were stored in a clean and sanitary manner for one of one resident (Resident (R) 47) reviewed for respiratory care of 41 sample residents. This failure had the potential to lead to oxygen equipment not properly maintained.

Inspectors wroteBased on medical record review and interview, the facility staff failed to administer pain medications to manage a resident's pain in a timely manner (Resident #203). This was evident for 1 of 41 residents reviewed during an annual/complaint survey.

Inspectors wroteBased on observation, interviews, record reviews, and policy reviews, the facility failed to follow infection control and prevention guidelines as follows: 1. The facility staff did not don (put on) personal protective equipment (PPE) prior to entering two resident's rooms for two of two residents (Residents (R) 1 and R19), that were on droplet and contact precautions and had COVID. 2. The facility staff did not wash their hands and change gloves after removing the dressing and cleaning the pressure ulcers during a wound care observation for R26. 3. The facility staff did not review the Legionella policies annually. This failure had the potential to affect the spread of infections.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure one of twenty-two baseboard heater covers was in good repair on the 100 Hall of the East Wing for one of one resident (Resident (R) 17) of 41 sample residents. This failure had the potential to cause injury to the residents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to submit the required staffing information based on payroll data in a uniform format by the required deadline. The facility failed to submit data for quarter three (April 1-June 30, 2024) of the federal fiscal year.

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to provide treatment and care in accordance with the physician's order to administer a pureed diet with honey-thickened liquids to Resident #1 and failed to follow standards of care following a life-threatening choking event. The facility's failure resulted in Immediate Jeopardy when Resident #1 on 12/20/23, suffered a choking episode and subsequently died. This was identified for 1 of 6 residents reviewed during a complaint survey. On 01/25/24 an Immediate Jeopardy (IJ) was identified. The facility Administrator received the IJ template on 01/25/24 at 4:10 PM and was notified that there was Immediate Jeopardy (IJ) identified due to the above failures. The facility IJ abatement plan was accepted on 01/24/24 at 9:45 PM.

Inspectors wroteBased on policy review, job description review, medical record review, observations, and interviews, the facility failed to provide the needed assistance and supervision with meals. The facility's failure resulted in harm when Resident #1 was left alone and choked after consuming a slice of pizza. This was identified for 1 of 6 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to immediately notify a resident's physician and representative when a resident was observed pocketing food. This was evident for 1 (Resident #4) of 6 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to take steps to 1) address a change in a resident's ability to swallow, 2) follow the resident's care plan and assist resident with meals, and 3) document the resident's meal percentage consumed for each meal. This occurred when a resident was observed pocketing food. This was evident for 1 (Resident #4) of 6 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Residents #3 and #4) of 6 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, facility documentation review and staff interview, it was determined that the facility staff failed to protect a resident (Resident #94), who was totally dependent on staff for all aspects of activities of daily living, from an accident with injury. The failure of staff to follow the resident's person-centered care plan after transferring the resident from the bed to the wheelchair, by not securing the vest restraint and having the second staff member stay in the room until the vest restraint was secure, resulted in the resident falling face forward onto the floor and sustaining a laceration which required 4 sutures and a likely non-displaced nasal bone fracture. Additionally, the staff failed to follow physician's orders and a care plan for a second resident (Resident #28) who was a fall's risk. [...]

Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 3 out of 3 personnel files reviewed.

Inspectors wroteBased on interview of facility staff, it was determined the facility staff failed to ensure a full-time qualified dietetic service supervisor for oversight of food preparation and daily kitchen operation.

Inspectors wroteBased on observation and staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on all nursing units.

Inspectors wroteBased on medical record review and staff interview, it was determined that the physician progress notes and/or history and physicals were not in the medical record after each visit. This was evident for 1 (#94) of 1 resident reviewed for edema, 1 (#93) of 4 residents reviewed for accidents, 1 (#48) 2 residents reviewed for nutrition, 1 (#24) of 1 resident reviewed for pain, and 1 (#3) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to assure that residents are seen by a physician at least once every 30 days for the first 90 days, and at least once every 60 days thereafter. This was evident for 1 (#48) of 2 residents reviewed for nutrition and 1 (#8) of 3 residents reviewed for dementia care.

Inspectors wroteBased on review of facility documentation and interviews with the facility staff, it was determined the facility failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address deficiencies from a previous survey. This was evident during review of the Quality Assurance program.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to follow a resident's MOLST form related to medical tests. This was evident for 1 (#11) of 1 residents reviewed for hospice and end of life care.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 2 (#64, #94) of 4 residents reviewed for hospitalization following a fall.

Inspectors wroteBased on resident representative and resident interview, observation, medical record review and staff interview, it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident for 1 (#5) of residents reviewed for respiratory.

Inspectors wroteBased on medical record review, observation and staff interview, it was determined the facility failed to 1) develop a respiratory, resident centered care plan for a resident requiring continuous oxygen and 2) failed to label oxygen tubing when initiated. This was evident for 1 (#5) of 1 resident's reviewed for respiratory and 1 (#7) of 1 resident's reviewed for personal property.

Inspectors wroteBased on medical record review and staff interview, it was determined the physician failed to monitor changes related to a resident's weight during monthly visits. This was evident for 1 (#48) of 2 residents reviewed for nutrition.

Inspectors wroteBased on observation, staff interview and facility documentation review, it was determined the facility staff failed to label medications when opened and discard medications when expired. This was evident for 1 of 4 medication carts observed.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to have laboratory reports filed in the resident's clinical record. This was evident for 1 (#11) of 1 resident's reviewed for hospice services and end of life care.

Inspectors wroteBased on a complaint allegation (MD00139328), medical record review and staff interview, it was determined that the facility failed to keep complete and accurate medical records. This was evident for 1 (#11) of 1 resident reviewed for hospice and end of life care and 1 (#145) reviewed for a complaint allegation.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to label and store resident care equipment in a manner to prevent development and transmission of disease and infection. This was evident for 1 (room [ROOM NUMBER]) of 4 rooms in the 500 hall observed during the survey.