Mid City Community Nursing and Rehab

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure: Food was properly stored, labeled and dated with an open date, or discarded for safety; and Staff documented food temperatures on food served to residents. There were 114 residents who received food served from the kitchen. Review of facility's policy titled, Food Safety Requirements, last revised August 2022, revealed the following, in part:Policy: It is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Policy Explanation and Compliance Guidelines: 1. B. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop a trauma-informed, comprehensive person-centered care plan, which included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 (#14) of 30 Residents reviewed in the final sample. The facility failed to develop a care plan for Resident #14's diagnosis of Post-Traumatic Stress Disorder (PTSD). Review of Resident #14's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of PTSD. Review of Resident #14's most current care plan revealed no documented evidence of a care plan for diagnosis of PTSD. On 04/08/2026 at 1:25 p.m., an interview was conducted with S4LPN. S4LPN stated he was unaware Resident #14 had a diagnosis of PTSD and confirmed he was not familiar with Resident #14's triggers that may result in a mental health crisis. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure a medication cart was free of unlabeled capsules for 1 (Cart A) of 2 medication carts reviewed. Review of facility's policy titled, Labeling of Medications and Biologicals, last revised October 2020, revealed the following, in part: Policy: All medications and biologicals in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: 1. All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#2) of 1 resident reviewed for Enhanced Barrier Precautions (EBP). The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing care to a resident who was on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident's call light was within reach for 1 (#4) of 22 residents reviewed in the final sample.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (#4 and #50) residents out of a total of 22 sampled residents. The facility failed to ensure: 1. Resident #4 was coded correctly for functional abilities and goals; and 2. Resident #50 was coded correctly for medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's laboratory tests were completed as ordered by the physician for 1(#52) of 22 residents investigated in the final sample.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the results from the most recent complaint survey was readily available for resident review. This deficient practice had the potential to affect the 104 residents who currently resided in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to protect the residents' right to be free from physical abuse for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) sampled residents reviewed for physical abuse. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. This deficient practice resulted in an actual physical harm on 01/18/2025, when Resident #1, a cognitively intact Resident, punched Resident #2 in his face three times. Resident #1 was diagnosed with Unspecified Fracture of Fifth Metacarpal Bone of his Right Hand on 01/20/2025.

Inspectors wroteBased on interviews and record review, the facility failed to ensure allegations of physical abuse were reported to the facility's administrator and the state agency in an appropriate time frame for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) residents reviewed for physical abuse. The facility failed to ensure: 1. Staff immediately reported physical abuse to administration when Resident #1 and Resident #2 got into a physical altercation; and 2. The administrator reported 3 separate incidents of physical abuse involving Resident #1 and #2; Resident #2 and #3; and Resident # 1 and #4 to the state survey agency. This deficient practice resulted in an actual physical harm on 01/18/2025, when Resident #1, a cognitively intact Resident, punched Resident #2 in his face three times. Resident #1 was diagnosed with Unspecified Fracture of Fifth Metacarpal Bone of his Right Hand on 01/20/2025.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents with an identified mental health diagnosis were referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for PASARR.

Inspectors wroteBased on interviews and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to ensure: 1. Residents with newly diagnosed mental illnesses were reevaluated for PASRR Level II determinations for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for PASRR; and 2. Allegations of physical abuse were reported to the state agency, immediately but not later than 2 hours after the allegation for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) residents reviewed for abuse; and 3. [...]

Inspectors wroteBased on record review and interviews, the facility to ensure nursing staff communicated a significant change in status to the residents' nurse practitioner for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for notification of change.

Inspectors wroteBased on observation, record review, and interviews the facility failed to protect the resident's right to be free from verbal and mental abuse by a staff member for 1 (#116) of 22 residents reviewed in the final sample. This deficient practice resulted in psychosocial harm on 04/18/2024 at 11:24 a.m. when surveyor observed S10CNA provide care to Resident #116, a [AGE] year old moderately cognitively impaired resident with a diagnosis of Guillain Barre Syndrome. Upon S10CNA entering the room, Resident #116 became visibly tense throughout her body, hands clenched into tight fist around the side rail, and her eyes filled with tears. S10CNA rushed through care then became argumentative with a rude, aggressive tone and tense body language after the resident requested to have her teeth brushed. This interaction left Resident #116 tearful and her body language tense. [...]

Inspectors wroteBased on interview and record review, the facility failed to incorporate the recommendations from Preadmission Screening and Resident Review (PASRR) Level II Determinations and PASRR Evaluation Reports into resident's assessment, care planning and transitions of care for 3 (#12, #24 and #63) of 8 (#12, #24, #39, #50, #63, #71, #72, and #101 ) reviewed for PASRR.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, and distribute foods under sanitary conditions by failing to maintain a clean kitchen environment. There were 109 facility residents residing in the facility who received food from the facility's kitchen.

Inspectors wroteBased on interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to ensure: 1. Recommendations from PASRR Level II Determinations and PASRR Evaluation Reports were incorporated into a resident's assessment, care plan and transitions of care for 3 (#12, #24, #63) of 8 (#12, #24, #39, #50, #63, #71, #72, #101) residents reviewed for PASRR; and 2. The coding accuracy for Minimum Data Set assessments regarding PASRR Level II for 1 (#12) of 8 (#12, #24, #39, #50, #63, #71, #72, #101) residents reviewed for PASRR. The deficient practice had the potential to affect a census of 110 residents. Cross Reference F641. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the residents' status by failing to ensure a resident's Minimum Data Set was accurately coded for PASRR Level II (Pre-admission Screening and Resident Review) for 1 (#12) of 8 (#12, #24, #39, #50, #63, #71, #72, and #101) sampled residents reviewed for PASRR.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a comprehensive person-centered plan of care by failing to follow Physician's Orders for 1 (#45) of 4 (#4, #43, ##66, #114) residents reviewed for nutrition. The facility failed to ensure Resident #45 received a House Supplement with Meals three times daily.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that appealing options of similar nutritive value were offered to residents who choose not to eat food that is initially served or who request a different meal choice for 1 (#45) of 32 sampled residents reviewed in the initial pool.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#39) of 32 residents reviewed for advanced directives in the initial screening process.

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing catheter care for 1 (#12) of 3 (#12, #52 and #102) sampled residents reviewed for catheter care.