Medallion Post Acute Rehabilitation

Inspectors wroteBased on observations, record review and interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, the facility failed to:-Maintain residents' dignity and ensure call lights were answered timely; and,-Ensure residents were treated with dignity by staff during meal service.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in one of two medication carts and one of one medication storage room. Specifically, the facility failed to:Ensure medications were labeled with the date they were opened;-Ensure expired medications were disposed of; and, -Ensure there were no loose pills in the bottom of the medication cart's drawers.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to: -Ensure the facility was kept free from mice, spiders and other insects; and,-Consistently follow recommendations from the pest control company to decrease the potential for mice, spiders and other insects to enter the facility.

Inspectors wroteBased on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for two (#5 and #40) of 24 residents reviewed out of 41 sample residents. Specially, the facility failed to:-Ensure Resident #5's medical orders for scope of treatment (MOST) form matched the computerized physician orders (CPO) for cardiopulmonary resuscitation (CPR); and,-Ensure Resident #40's MOST form matched the CPO for no CPR.

Inspectors wroteBased on observations, record review and interviews, the facility failed to communicate effectively with the dialysis centers for one (#3) of two residents reviewed for dialysis out of 41 sample residents. Specifically, the facility failed to ensure pre- and post-dialysis assessments for Resident #3 were completed and documented per professional standards.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure received routine dental care obtaining routine and 24-hour emergency dental care for one (#7) of three residents reviewed for ancillary services out of 41 sample residents. Specifically, the facility failed to provide dental services for Resident #7, who had been identified as having dental decay.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to ensure the correct nurse staffing information was updated daily.

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for one (#2) of three residents out of nine sample residents. Resident #2, who had a history of falling and previous fractures that included a burst fracture of the thoracic vertebra (bone in the upper spine caused by trauma), was admitted to the facility on [DATE]. On 2/11/25 at 6:45 a.m. Resident #2, who ambulated independently with her walker, slipped and fell while walking to the bathroom. After the fall, Resident #2 was heard yelling. A licensed practical nurse (LPN) went to check on the resident and found her lying on her left side, complaining of 8 out of 10 pain, on a 1 to 10 pain scale, to her left shoulder and left hip. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents at risk for elopement out of seven sample residents received adequate supervision and were kept free from elopement. Specifically, the facility failed to provide Resident #1 the supervision necessary to prevent elopement. The facility failures created a situation with serious harm and a situation of likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1, diagnosed with metabolic encephalopathy (improper brain function due to underlying medical condition), unspecified psychosis (mental condition caused by loss of contact with reality), dementia and anxiety, eloped from the facility on 2/1/25 at an unknown time. Facility staff were unaware Resident #1 was missing until after 6:00 a.m. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#4) of two residents reviewed out of 33 sample residents. Resident #4 was admitted on [DATE] for long term care with diagnoses of type 2 diabetes with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failures, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. On 7/12/24 Resident #4 struck her right lower leg on the side of her metal bed frame when she was maneuvering her electric wheelchair near her bed, causing a hematoma (bruise) to her leg. The resident reported the injury was very painful. [...]

Inspectors wroteVI. Resident #23 A. Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the August 2024 CPO, diagnoses included hemiplegia and hemiparesis (impaired communication between the brain and muscles) and chronic systolic (congestive) heart failure. The 2/2/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He was dependent on staff assistance for showering/bathing himself, lower body dressing, putting on/taking off footwear, lying to sitting, sitting to stand, chair to bed and bed to chair transferring and tub/shower transferring. B. Resident interview Resident #23 was interviewed on 8/14/24 at 8:49 a.m. Resident #23 said his roommate kept the television on all the time and it was loud. He said he could not hear his television and could not sleep due to the noise level. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to make prompt efforts to resolve resident grievances about a variety of concerns, including grievances not being answered in a timely manner, staffing shortages with provision of timely care and responding to resident call lights.

Inspectors wroteBased on observations and interviews, the facility failed to provide a clean, comfortable and homelike environment for residents. Specifically, the facility failed to ensure resident rooms, bathrooms and hallways received necessary maintenance repairs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#18, #45 and #5) of three residents reviewed for assistance with ADLs out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #18 and #45's fingernails were trimmed and clean; and, -Ensure Resident #5 received staff assistance with getting dressed.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of three medication carts and one of one medication storage rooms. Specifically, the facility failed to: -Ensure controlled medications were securely stored under double lock; -Ensure expired medications were removed from the medication carts and the medication storage room; and, -Ensure medications were labeled with an expiration date.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity for two (#4 and #5) of five residents reviewed out of 33 sample residents by providing care in a dignified, respectful and individualized manner. Specifically, the facility failed to: -Ensure staff knocked or announced themselves prior to entering Resident #4's room; and, -Ensure Resident #5 was provided with timely incontinence care when requested.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide reasonable accommodations necessary to accommodate mobility and accessibility in the resident's environment for one (#8) of one resident reviewed out of 33 sample residents. Specifically, the facility failed to ensure Resident #8's call light was consistently accessible to her.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#4) of three residents out of 33 sample residents was provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a resolution to Resident #4's grievance, which he had communicated to staff on multiple occasions, regarding the resident's care.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that professional standards of practice were followed during medication administration for one (#4) of one resident reviewed out of 33 sample residents. Specifically, the facility failed to ensure medications were not left at Resident #4's bedside.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement effective discharge planning for one (#59) of two residents reviewed for discharge planning out of 33 sample residents. Specifically, the facility failed to develop and implement a collaborative discharge plan that involved Resident #59's discharge goals.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#39) of one resident out of 33 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Specifically the facility failed to provide Resident #39 meal set-up assistance and implement nutritional interventions to prevent weight loss.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#59) of one resident out of 33 sample residents was free of significant medication errors. Specifically, the facility failed to ensure Resident #59 was administered medication in regular intervals for Parkinson's disease according to the manufacturer recommendations, which resulted in the resident experiencing increased tremors, a symptom of his Parkinson's disease.

Inspectors wroteBased on record review and interviews,, the facility failed to assist residents in obtaining routine or emergency dental services, as needed for two (#23 and #18) of four residents reviewed for dental services out of 33 sample residents. Specifically, the facility failed to ensure: -Dental services were offered to Resident #23; and, -Resident #18 was provided dentures in a timely manner.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of three units. Specifically, the facility failed to: -Ensure housekeeping staff disinfected high touch surfaces (call lights, door handle and light switches) in resident rooms; -Ensure surface disinfectant dwell times (the amount of time a disinfectant needs to remain wet on a surface to effectively kill germs) were followed; -Ensure areas were cleaned from clean areas to dirty areas; and, -Ensure hand hygiene was performed appropriately during the cleaning of residents' rooms.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible, affecting three (#1, #2, and #3) out of five residents. Interviews with leadership revealed the facility had transitioned in March 2024 from a non-smoking to a smoking facility. However, a review of the facility's smoking policy (revision date 9/8/22) and the resident smoking safety evaluation in effect in March 2024, revealed they were not reviewed and revised and failed to address oversight and safety interventions for staff to implement as a smoking facility. Further, there were no resident smoking agreements since the transition. None of these documents included adequate consideration of the risks and the procedures to ensure the safety of residents with an order for oxygen who smoked. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#6) of two residents reviewed for falls out of 23 sample residents. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living as documented in her 10/19/22 minimum data set (MDS) assessment. The facility failed to provide staff education and increase resident's supervision to prevent falls when she could not initiate staff assistance by using her call light due to severely impaired cognition. Due to the facility's failures, lack of appropriate supervision and effective interventions resulted in four falls. [...]

Inspectors wroteBased on record review and interviews, the facility failed to communicate and collaborate with the hospice provider to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (#8) out of two residents reviewed for hospice care of 23 sample residents. Specifically, the facility failed to for Resident #8: -Collaborate with the hospice provider to develop a coordinated plan of care; and, -Ensure adequate communication and documentation between the facility and the hospice provider occurred.

Inspectors wroteBased on record review and interviews, the facility failed to inform two (#24 and #41) of three out of 23 sample residents reviewed for liability notices and appeal rights changes in their services covered by Medicare. Specifically, the residents were not provided with completed skilled nursing facility-advanced beneficiary notice after Medicare coverage ended and the residents remained in the facility.