Emporia Rehabilitation and Healthcare Center

Inspectors wroteBased on staff interview, clinical record review, and facility record review, the facility failed to have evidence that alleged violations were investigated thoroughly for 1 of 28 residents in the sample, Resident #117 (R117).

Inspectors wroteBased on resident interview, staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 28 residents in a survey sample, Resident #97.

Inspectors wroteBased on interviews and clinical record review, the facility staff failed to notify the Nurse Practitioner and resident's Responsible Party immediately of a significant change condition for 1 resident (Resident #1) in a survey sample of 6 residents.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents are free from significant medication error for 1 resident (#2) in a survey sample of 6 residents. For Resident #2 the facility staff failed to follow the physician orders for parameters on administering the drug Midodrine (an alpha-Adrenergic Agonist used to raise blood pressure). Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Interstitial pulmonary disease, generalized anxiety disorder, major depressive disorder, unspecified dementia, dysphagia, Barretts esophagus, and generalized weakness. [...]

Inspectors wroteBased on interviews and clinical record review, the facility staff failed to ensure appropriate resident care and services were provided in accordance with accepted professional standards of care for 1 resident (Resident #1) in a survey sample of 6 residents.

Inspectors wroteBased on staff interview, Family interview, facility documentation review, and clinical record review, the facility staff failed to maintain the professional standards of nursing practice for one Resident (Residents #1) in a survey sample of 2 Residents. For Resident #1, the facility staff failed to send the Resident to the hospital for 32 hours after a fall with injury, notably chest bruising and obvious pain with facial grimacing upon palpation of the injury by a nurse Practitioner immediately following the injury.

Inspectors wroteBased on staff interview, clinical record review, the facility staff failed to notify the family of a change in condition for one Resident (Resident # 4) in a survey sample of 8 residents.

Inspectors wrotetwo Residents (Resident # 2 and #6) in a survey sample of 8 Residents.

Inspectors wroteBased on staff interview, facility documentation and clinical record review, the facility staff failed to review and revise the care plans for 3 Residents (Residents # 1, #2, and # 3) of 8 Residents in the survey sample.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure care and services met professional standards of quality for one Resident (Resident # 4) in a survey sample of 8 residents.

Inspectors wroteBased on staff interview, and clinical record review, the facility failed to provide care and services to ensure one Resident (Resident # 4) in a survey sample of 8 residents received care and services for Activities of Daily Living. (ADLs).

Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure one Resident (Resident # 4) in a survey sample of 8 residents, received care and services to prevent and identify an infected pressure ulcer.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation, the facility staff failed to provide appropriate treatment and services for Residents who display or are diagnosed with mental disorder or psychosocial adjustment difficulty for one Resident (Resident #4) in a survey sample of 8 Residents.

Inspectors wroteBased on staff interview, clinical record review and facility documentation, the facility staff failed to provide appropriate treatment and services for Residents who display or are diagnosed with dementia for one Resident (Resident #4) in a survey sample of 8 Residents.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure medications were available for administration for two Residents (Residents # 6 and # 3 ) in a survey sample of 8 residents.

Inspectors wroteBased on interview, clinical record review and facility documentation, the facility staff failed to ensure that a Resident was free from unnecessary medications to include duplicate drug therapy for one Resident (Resident #4) in a survey sample of 8 Residents.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure Resident was free from unnecessary psychotropic drug use for one Resident (Resident #4) in a survey sample of 8 Residents.

Inspectors wroteBased on staff interview and facility record review, the facility staff failed to have a sufficient surety bond to assure the security of all personal funds of residents deposited with the facility, affecting 85 of 93 facility Residents who had a patient trust account.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to implement their abuse policy for 14 employees (Staff #3, 8, 11, 12, 16, 19, 21, 22, 24, 25, 32, 33, 34 and 35) in a sample of 25 employees reviewed.

Inspectors wroteBased on observations, staff interviews, and facility documentation review, the facility staff failed to remove expired medications and supplies from the supply that was available for administration to residents in 1 of 3 medication carts, and in 2 of 3 medication storage rooms inspected.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to follow proper sanitation protocol to prevent a potential outbreak of foodborne illness for 5 out of 12 days in November 2022.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to implement effective infection control practices for one out of one building, and in one of three care units.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with CDC (Centers for Disease Control) and CMS (Centers for Medicare & Medicaid Services) guidance/requirements during a facility wide COVID-19 Outbreak for facility staff and residents; and the facility staff failed to conduct COVID-19 testing for 2 residents, Residents #85 and #93, out of 2 newly admitted residents reviewed for COVID testing.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to convey a resident's personal funds within 30 days of discharge to one resident, (Resident #303), in a survey sample of 37 Residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to notify the responsible party for a change in condition for one Resident (Resident #80) in a sample size of 37 Residents.

Inspectors wroteBased on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a homelike environment for one Resident (Resident #11) in a sample size of 37 Residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure that Residents are free from abuse and exploitation for 1 Resident (Resident #303) in a survey sample of 37 Residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to permit a resident to return to the facility for one Resident (Resident #300) in a survey sample of 37 Residents.

Inspectors wroteBased on clinical record reviews, staff interviews, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards of practice for 2 Residents (Resident #80, Resident #299) in a sample size of 37 Residents.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to complete a discharge summary to include recapitulation of stay for 1 resident (Resident #99) in the survey sample of 37 residents.

Inspectors wroteBased on Staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to provide adequate nutrition and hydration for one Resident (Resident #99) in a survey sample of 37 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide influenza vaccines for 3 residents, Residents #5, #8, and #34, out of 5 residents reviewed for influenza immunization; and facility staff failed to provide a pneumococcal vaccine for 1residents, Resident #8, out of 5 residents reviewed for pneumococcal immunization.

Inspectors wroteBased on staff record review, staff interview, and facility documentation review, the facility staff failed to provide COVID-19 immunization for 1 resident, Resident #77, in a survey sample of 5 residents reviewed for COVID-19 vaccination.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed to provide quality of care for three Residents (Resident #53, Resident #81, and Resident #41) in a survey sample of 35 Residents. 1. For Resident #53, the facility staff failed to assess the resident to determine the cause of her distress (i.e. crying), and seek appropriate treatment. The resident was documented as crying for 9 of 16 days. 2. For Resident #81, the facility staff failed to identify, assess, treat and monitor a skin wound on his left upper forearm. 3a. For Resident #41, the facility staff failed to document the administration of multiple medications during April, 2019. 3b. For Resident #41, the facility staff failed to administer five doses of physician-ordered insulin in April, 2019.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. 1. Facility staff failed to provide a sanitizing solution with appropriate concentration levels to ensure adequate sanitization during manual dishwashing. 2. Facility staff failed to properly label and date food items stored in the walk-in freezer. 3. Facility staff failed to follow appropriate hygiene/sanitary procedures by not wearing a hairnet in the kitchen.

Inspectors wroteBased on staff interview, facility documentation review, facility staff failed to complete an Advanced Beneficiary Notice (ABN) for one (Residents # 60) of 3 sampled residents. 1. For Resident # 60, the facility staff did not complete an Advanced Beneficiary Notice (ABN) timely.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to provide a clean environment for one resident (Resident #81) in a sample size of 35 residents. The bathroom in Resident #81's room had mold on the floor, had a strong odor of mold and urine, and the hot water handle on Resident #81's room sink was loose.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed for one resident (Resident #72), in the survey sample of 35 residents, to notify the Ombudsman of a hospital transfer. The facility staff failed to notify the Ombudsman that Resident #72 had been transferred to the hospital.

Inspectors wroteBased on staff interview, facility documentation and clinical record review the facility failed to ensure that a Level II PASARR (Pre admission Screening And Resident Review) was performed prior to admission for 1 Resident (# 45) in a survey sample of 35 Residents. For Resident #45, the facility staff failed to obtain a PASARR prior to admission.

Inspectors wroteBased on observations, resident interviews, staff interviews, clinical record review, and facility documentation, the facility staff failed to develop comprehensive, resident-centered care plan for 2 residents (Resident #14, Resident #81) in a sample size of 35 residents. 1. For Resident #14, the facility staff failed to develop and implement an Activities program. 2. For Resident #81, the facility staff failed to develop a plan of care for a skin wound on his left upper forearm.

Inspectors wroteBased on staff interview, facility documentation review and clinical record review the facility staff failed to review and revise the careplan for three residents (Resident #22, Resident #43, and Resident #81) in a survey sample of 35 residents. 1. For Resident #22, the facility staff failed to review and revise the careplan to include the physician ordered, pureed diet with nectar thick liquids. 2. For Resident #43, the facility staff failed to review and revise the careplan to include the physician ordered palm guards. 3 For Resident #81, the facility staff failed to revise the care plan on the status of an anti-anxiety medication.

Inspectors wroteBased on observations, staff interviews, clinical record review, and facility documentation, the facility staff failed to plan and implement Activities for one resident (Resident #14) out of a sample size of 35 residents.

Inspectors wroteBased on observation, staff interview, and clinical record review the facility staff failed to provide services to prevent the development of pressure ulcers for one resident (Resident #22) in a survey sample of 35 Residents. For Resident #22, the facility staff failed to provide prevalon boot to left foot, as ordered by the physician, to prevent the development of a pressure ulcer.

Inspectors wroteBased on observation and clinical record review the facility staff failed to provide services to prevent the decline in ROM (range of motion) for one resident (Resident #43) in a survey sample of 35 Residents. For Resident #43, the facility staff failed to provide palm guards, as ordered by the physician, to prevent the decline in ROM.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to ensure the environment was free of accident hazards on one of three nursing units. The facility staff failed to lock and secure a housekeeping cart on the 200 hall, which included chemicals and a sharp object.

Inspectors wroteBased on staff interview, clinical record review and facility documentation, and hospital discharge record review the facility staff failed to ensure Residents free from unnecessary medications for 1 Resident (#77) in a survey sample of 35 Residents. For Resident #77 the facility staff failed to hold or discontinue Colace 100 (Milligrams) mg twice daily [given for constipation] when the Resident had loose stools since readmission from the hospital.

Inspectors wroteBased on resident representative interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide dental services for one resident (Resident #53) in a survey sample of 35 residents. The facility staff failed to provide routine dental services for Resident #53.

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to provide a therapeutic diet, as ordered by the physician, for one resident (Resident #22) in a survey sample of 35 Residents. For Resident #22, the facility staff failed to nectar thick liquids as ordered by the physician.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to maintain an accurate medical record for 2 residents (Resident #22 and Resident #43) in a survey sample of 35 Residents. 1. For Resident #22 the facility staff failed to conduct a quarterly review of Resident #22, to determine that placement in a secure unit continued to be appropriate for the resident. 2. For Resident #43 the facility staff failed to conduct a quarterly review of Resident #43 to determine that placement in a secure unit continued to be appropriate for the resident.

Inspectors wroteBased on staff interview, and facility documentation review, the facility staff failed to maintain a Quality Assessment and Assurance (QAA) Committee consisting of the minimum members in two of four quarters from April 2018- March 2019. 1. For the April 24, 2018 Quarterly QAA meeting, the administrator was not in attendance and the Administrator and Director of Nursing did not attend the January 28, 2019 Quarterly QAA meeting.

Inspectors wroteBased on observation, staff interview, resident interview, facility documentation review, and clinical record review, the facility staff failed to ensure infection prevention for 1 Resident (Resident #36) in a survey sample of 35 Residents. For Resident #36, the facility staff failed to ensure a partially full urinal was not present by his plate of food during meal services.

Inspectors wroteBased on observation, resident representative interview, and staff interview the facility staff failed to maintain equipment in safe operating condition for one resident (Resident #53) in a survey sample of 35 residents. The facility staff failed to maintain the bed and room in safe repair for Resident #53.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review the facility staff failed for 1 resident (Resident #66) of 21 residents in the survey sample to prevent and identify an unable to stage sacral pressure wound resulting in harm. Resident #66's sacral wound was first identified as unable to stage with 100% slough (dead tissue) present in the wound bed.

Inspectors wrote4. For Resident # 64 the facility failed to document medications as having been administered. Resident #64, a [AGE] year old, was admitted to the facility on [DATE]. His diagnoses included diabetes, chronic kidney disease, pressure ulcer, and hypertension. The most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 12/19/17. He was coded with a Brief Interview of Mental Status score of 15 indicting no cognitive impairment. He required extensive assistance with activities of daily living. Resident #64's January 2018 Medication Administration Record (MAR) was reviewed. On the 3-11 shift, there were multiple instances where the nurse failed to document the administration of medications. Medications were not documented as having been administered on the following occasions: Docusate 9:00 p.m.: 1/4/18, 1/15/18, 1/17/18 and 1/22/18 Acetaminophen 8: [...]

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to provide activities for six residents (Residents # 65, 47, 46, 83, 10 and 60) in a survey sample of 21 residents. 1. For Resident # 65, the facility staff failed to provide Activities to residents during survey 1/24/2018 through 1/26/2018. 2. For Resident # 47, the facility staff failed to provide Activities during 3 days of survey 1/24-1/26/2018. 3. For Resident # 46, the facility staff failed to provide Activities during 3 days of survey 1/24-1/26/2018. 4. For Resident # 83, the facility staff failed to provide Activities during 3 days of survey 1/24-1/26/2018. 5. No meaningful activities were assessed for, nor planned for Resident #10. 6. No meaningful activities were assessed for, nor planned for Resident #60.

Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed for 1 resident (Resident #64) of 21 residents in the survey sample to ensure pharmacy recommendations were acted upon. For Resident #64, the pharmacist recommended that the facility obtain a digoxin level nine times before the level was obtained.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure five Residents were free from significant medication error (Residents #10, 29, 40, 83, and 47) in a survey sample of 21 Residents. 1. For Resident #10, the facility failed to administer anti seizure medication as ordered by a physician. 2. For Resident #29, the facility failed to administer insulin as ordered by a physician. 3. For Resident #40, the facility failed to administer anti seizure medication as ordered by a physician. 4. For Resident # 83, the facility staff failed to document the administration of Insulin for Diabetic Management and Anti-seizure medications. 5. For Resident # 47, the facility staff failed to document the administration of anti-seizure medications as ordered by the physician.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review the facility staff failed for 1 resident (Resident #77) of 21 residents in the survey sample to ensure the resident had been assessed to self administer medications. Resident #77's medications were left at the bedside. She took the medications without supervision.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to notify the responsible party of falls for 1 Resident (Resident #60) in a survey sample of 21 Residents. For Resident #60, the facility staff failed to notify the Responsible party of recurring falls.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed for 1 resident (Resident #65) of 21 residents in the survey sample to ensure personal privacy. For Resident #65, the facility staff failed to knock on the door, and or announce themselves prior to entering the bedroom.

Inspectors wroteBased on Observation and Staff Interview, the facility staff failed to maintain a safe, clean, comfortable environment for one resident (Resident #21) in a sample of 21 residents. For Resident #21, the right arm of the wheel chair was torn and taped.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to complete an accurate MDS (minimum data set) RAI (Resident Assessment Instrument) for two Residents (Resident #60 and Resident #66) in a survey sample of 21 Residents. For Resident #60, the facility staff failed to accurately code number of falls since admission (1900A), cognitive status (C0500) in the admission MDS, and Bowel and bladder Continence was also inaccurate from comparison between the care plan, MDS, and the CAA's.

Inspectors wroteBased on family interview, staff interview and clinical record review, the facility staff failed to provide a summary of the care and services for the Resident, to the Resident's Responsible party in a manner that was understandable to that individual. Also, the facility staff did not give updated interventions as they became available, for one Resident (Resident #60) in a survey sample of 21 Residents. For Resident #60, the facility staff failed to provide the Responsible party with a baseline care plan of services, and failed to provide the Responsible party with revisions of care plan interventions as they became available and necessary.

Inspectors wroteBased on Observation, staff interview, facility document review, and clinical record review, the facility failed to develop a comprehensive care plan for two residents (Resident #60 and Resident #21) in a survey sample of 21 residents. 1. For Resident #60, the facility staff signed as having completed the comprehensive care plan, and failed to address all of the care areas triggered in the MDS assessment. 2. For Resident #21, the comprehensive care plan did not document that the resident suffered from chronic pain.

Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to provide diabetic management for one resident (Resident # 83) in a survey sample of 21 residents. For Resident # 83, the facility staff failed to obtain Finger Stick Blood Sugars (FSBS) and administer Insulin as ordered by the physician.

Inspectors wroteBased on resident interview, staff interviews, and clinical record review, the facility staff failed to ensure that pain management was provided to two residents (Resident #21 and Resident #77) in a sample of 21 Residents. 1. For Resident #21, facility Staff failed to offer physician ordered topical cream and other, non-pharmacological, pain control interventions. 2. For Resident #77, the facility staff failed assess pain and failed to administer pain medication when the resident expressed that she was in pain. The Findings Included: 1. For Resident #21, facility Staff failed to offer physician ordered topical cream and other, non-pharmacological, pain control interventions. Resident #21's diagnoses included: [...]

Inspectors wroteBased on staff interview and clinical record review the facility staff failed for 1 resident (Resident #64) of 21 residents in the survey sample to ensure the resident was free from unnecessary medications. For Resident #64, Cardizem (blood pressure medication) was administered when it should have been held.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure the resident was free from un-necessary medications for two residents, (Resident #71 and Resident #15) in a survey sample of 21 residents. 1. Resident #71's Ativan PRN (as needed) antianxiety medication was administered without assessing the resident at the end of every 14 day continued use, and renewing the PRN order every 14 days. 2. For Resident #15, the facility staff failed to ensure the resident was free from unnecessary medications.

Inspectors wroteBased on observation and staff interview the facility staff failed to store and serve food in accordance with professional standards for food service safety. A fan with dust caked on the back of the frame was found blowing air over the area where dishes were washed and racked to dry.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed, for two residents (Residents #10, and #60) to maintain a complete and accurate clinical record in the survey sample of 21 residents. 1. No meaningful activity records existed in the clinical record for Resident #10. 2. No meaningful activity records existed in the clinical record for Resident #60.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed for 1 resident (Resident #65) of 21 residents in the survey sample to practice appropriate hand washing prior to medication administration. And, the facility staff failed to have air gaps on the ice machines in the kitchen and on Unit 1. 1. For Resident #65, the facility staff failed to knock on the door, and or announce themselves prior to entering the bedroom. 2. The facility failed to have air gaps on the ice machines in the Kitchen and on Unit 1.