Family Health & Rehabilitation Center

Inspectors wroteThe facility identified a census of 66 residents and four kitchens. Based on observation, record review, and interviews the facility failed to maintain a sanitary environment and store food adequately to prevent contamination.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 12 had been assessed for the ability to safely self-administer his physician-ordered Fluticasone propionate nasal spray (a corticosteroid used to relieve allergy and nasal inflammation symptoms).

Inspectors wroteThe facility identified a census of 66. The sample included 18 residents. Based on record review and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 65.

Inspectors wroteThe facility identified a census of 66. The sample included 18 residents. Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 39 received the necessary staff assistance with oral hygiene.

Inspectors wroteThe facility identified a census of 66. The sample included 18 residents. Based on observation, record review and interviews, the facility failed to identify and implement interventions for Resident (R) 19 to address a nine-day period with no bowel movement.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with one reviewed for tube feeding (administration of nutritionally balanced liquified foods or nutrients through a tube). Based on observation, record review, and interview, the facility failed to provide appropriate care and services for Resident (R) 4 when staff administered a medication and provided a tube feeding without using the physician's order for the amount of water before and after the procedure.

Inspectors wroteThe facility reported a census of 66 residents. Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to protect Resident (R)25 and other vulnerable residents during the facility investigation after an abuse allegation. This placed R25 and the other residents under the care of Certified Nurse Aide (CNA) TT at risk for unidentified and ongoing abuse and /or neglect.

Inspectors wroteThe facility identified a census of 64 residents. The facility had four medication carts. Based on observation, record review, and interview, the facility failed to ensure accurate reconciliation of controlled substances (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed consistently. This placed residents at risk of medication misappropriation and diversion.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed five percent (%) when staff failed to ensure Resident (R) 12 was administered her scheduled morning medications within the ordered timeframe. The facility failed to ensure the insulin (a hormone that lowers the level of glucose in the blood) pen and needle were appropriately primed before insulin administration to R161. This resulted in a medication error rate of 46.15%.

Inspectors wroteThe facility identified a census of 64 residents. The facility had four medication storage refrigerators and four medication carts. Based on observation, record review, and interview, the facility failed to ensure safe and secure storage of medications and biologicals. This deficient practice created a risk of adverse side effects and ineffective medication administration.

Inspectors wroteThe facility identified a census of 64 residents. The facility identified 25 residents on enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care). Based on observations, record review, and interviews, the facility failed to ensure consistent infection control standards were followed related to enhanced barrier precautions, storage of oxygen tubing, indwelling catheter (tube placed in the bladder to drain urine into a collection bag) care, laundry, and shared equipment. These deficient practices placed the residents at risk for complications related to infectious diseases. [...]

Inspectors wroteThe facility had a census of 64 residents. The sample included 16 residents and three Certified Nurse Aides (CNAs) reviewed for 12 hours of required in-service training. Based on record review and interview, the facility failed to ensure three of the three CNA staff reviewed had the required 12 hours of in-service education which included the required dementia management training. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to ensure staff reported an allegation of staff-to-resident abuse for Resident (R) 25 to the facility administrator immediately. The facility additionally failed to report R25's allegation of abuse to the State Agency (SA) as required. This placed R25 at risk for unidentified and ongoing abuse and /or neglect.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents. One resident was sampled for accidents and hazards. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 42's fall interventions as directed by her care plan. This deficient practice placed R42 at risk of falls and related injuries.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents with three reviewed for urinary catheters (a tube inserted into the bladder to drain urine) care. Based on observations, record reviews, and interviews, the facility failed to follow standards of practices related to indwelling catheter care for Resident (R)44. This deficient practice placed R44 at risk for catheter-related complications including urinary tract infections (UTI).

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 39's access site for complications at least daily and failed to obtain communication from the dialysis center related to R39's treatment. These deficient practices placed R39 at risk of potential adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility reported a census of 64 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to follow the physician-ordered parameters related to Resident (R)17's as-needed (PRN) bumetanide (diuretic- medication to promote the formation and excretion of urine). This deficient practice placed R17 at increased risk for unnecessary medication and side effects.

Inspectors wroteThe facility census totaled 69 residents. Based on observation, interview, and record review, the facility failed to ensure infection control practices when direct care staff did not change gloves when going from dirty to clean areas while providing care to Residents (R) 41 and R25. The facility also failed to ensure all staff members and visitors appropriately completed all COVID-19 (respiratory virus) screening, including temperature and signs/symptoms questionnaire. These failures had the ability to affect all 69 residents in the facility.

Inspectors wroteThe facility census totaled 69 residents. Based on observation, interview, and record review, the facility failed to appropriately ensure all resident information was protected and kept private when a staff member left a computer screen unattended with resident information on the screen and visible.

Inspectors wroteThe facility reported a census of 69 residents with 17 included in the sample including one for hospitalization. Based on observation, interview, and record review the facility failed to send a copy of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long-Term Care Ombudsman for Resident (R) 34.

Inspectors wroteThe facility reported a census of 69 residents, with 17 sampled, including four for Activities of Daily Living (ADL). Based on observation, interview, and record review the facility failed to provide ADL assistance to include bathing services and shaving services to maintain good grooming for Residents (R) 9, who required limited assistance of one staff with bathing, and for R11, who required extensive assistance of one to two staff with bathing. Findings Included: - The 08/29/22 Electronic Health Record (EHR) documented R9 had the following diagnosis: hemiplegia (paralysis of one side of the body) of his right side. The 06/06/22 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. [...]

Inspectors wroteThe facility reported a census of 69 residents, with 17 included in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure staff monitored the efficacy of insulin (hormone which regulates blood sugar) when staff failed to obtain physician ordered blood glucose (BG, blood sugar) values and failed to notify the physician of BG values outside of the ordered parameters for R31 and R50.

Inspectors wroteThe facility census totaled 69 residents. Based on observation, interview and record review, the facility failed to appropriately ensure all medication carts remained locked when not in use by staff or when unattended.