Presentation Rehab and Skilled Care Center

Inspectors wroteBased on record review, interview, and observation, the facility failed to follow the plan of care for the use of a hand splint for one Resident (Resident #10), of 25 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to arrange for an appointment for one Resident (#38), out of a total of 25 sampled residents. Specifically, the facility failed to reschedule a cancelled Ear, Nose and Throat (ENT) specialist appointment for Resident #38.

Inspectors wroteBased on record review, interview, and observation, the facility failed to accurately document the use of a hand splint during the survey period for one Resident (Resident #10), of 25 sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure timely and accurate physician notification of a significant decline in status for one Resident (#109) out of a total sample of 27 residents. Specifically, for Resident #109, the facility failed to notify the physician or nurse practitioner when his/her respiratory status declined, resulting in the facility initiating a code blue (emergency response) and the Resident expired. Findings Include: Review of the facility policy titled Physician Notification, undated, included the following but not limited to: -Upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to the physician as indicated. [...]

Inspectors wrote2. Resident #109 was admitted to the facility in [DATE] with diagnoses that including acute chronic obstructive pulmonary disease (COPD) with acute exacerbation, respiratory failure with hypoxia (low oxygen level), shortness of breath, acute respiratory infection, parkinsonism, unspecified asthma, dysphagia, and personal history of pulmonary embolism. Review of the most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated that Resident #109 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and required assistance with activities of daily living. Review of Resident #109's MOLST (Medical Orders for Life Sustaining Treatment) indicated Resident #109 was a DNR (Do Not Resuscitate), DNI (Do not intubate), but wished to be transferred to the hospital in a medical emergency. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide a dignified dining experience for the residents on one of two floors (second floor). Specifically, the facility failed to ensure staff did not refer to residents by the level of assistance they required, and to serve all residents seated at the same table at the same time. Findings Include: Review of the facility policy titled, Dignity, revised June 2022, indicated the following: - Each resident shall be cared for in a manner that promotes and enhances his or herself well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. - Staff strive to treat residents with dignity and respect. - Staff speak respectfully to residents, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that concerns expressed by the Resident Council Group had sufficient follow-up to respond to and effectively resolve concerns or prevent recurrence.

Inspectors wroteBased on observation and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, on two of two floors.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure one Resident (#39) out of a total sample of 27 residents did not self-administer medication without an assessment or care plan.

Inspectors wroteBased on record review and interview, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, protection of residents during investigations, reporting of allegations and investigative findings, and taking corrective actions to protect other residents from potential abuse for two Residents, (#16 and #67), out of a total sample of 27 residents. Specifically: 1. For Resident #16, the facility failed to initiate their abuse policy after allegations of abuse were reported on grievance forms dated 6/17/24 and 7/23/24. 2. For Resident #67, the facility failed to initiate their abuse policy after allegations of abuse were reported on a grievance form dated 2/5/25.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse to the State Agency for two Residents (#16 and #67) out of a total sample of 27 residents. Specifically, 1. For Resident #16, the facility failed to report an allegation of abuse to the State Agency after allegations of abuse were reported on grievance forms dated 6/17/24 and 7/23/24. 2. For Resident #67, the facility failed to report an allegation of abuse to the State Agency after allegations of abuse were reported on a grievance form dated 2/5/25.

Inspectors wroteBased on record review and interviews, the facility failed to investigate allegations of abuse for two Residents (#16 and #67) out of a total sample of 27 residents. Specifically, 1. For Resident #16, the facility failed to implement their abuse policy and conduct investigations after allegations of abuse were reported on grievance forms dated 6/17/24 and 7/23/24. 2. For Resident #67, the facility failed to implement their abuse policy and conduct an investigation after allegations of abuse were reported on a grievance form dated 2/5/25.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one Resident (#78) out of a total sample of 27 residents. Specifically, the facility failed to ensure that the MDS assessment for Resident #78 coded for a significant change when the Resident signed onto hospice.

Inspectors wroteBased on observation, record review and interviews, the facility failed to implement the care plan of one Resident (#74), out of a total sample of 27 residents. Specifically, the facility failed to ensure alarms and floor mats were in place as per the care plan.

Inspectors wrote3a. Resident #16 was admitted to the facility in June 2024 with diagnoses including unspecified dementia, dysphagia, adjustment disorder with mixed anxiety and depressed mood, weakness and difficulty walking. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/12/25, indicated that Resident #16 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15. The MDS further indicated Resident #16 was dependent on staff for functional tasks and was at risk of developing pressure ulcers/injuries and required a pressure reducing device for bed and chair. Review of Resident #16's physician order dated 3/24/25 indicated: Air mattress to prevent pressure injuries. Every shift for Pressure sore prevention. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLS) for one Resident (#67) out of a total of 27 residents. Specifically, the facility failed to ensure that the Resident was offered and/or provided showers.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#54) out of a total sample of 27 residents. Specifically, the facility failed to ensure recommendations from behavioral health services were relayed to the physician and implemented for Resident #54.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a current hospice plan of care was present in the medical record and coordinated with facility staff for one Resident (#78) out of a total sample of 27 residents. Resident #78 was admitted to the facility in June 2024 with diagnoses including malignant neoplasm of colon and failure to thrive. Review of Resident #78's Minimum Data Set (MDS) assessment, dated 9/18/24, indicated the Resident scored a 9 out of possible 15 on the Brief Interview for Mental Status exam, indicating he/she had moderate cognitive impairment. The MDS further indicated that the Resident was receiving hospice services. Review of Resident #78's medical record indicated the following: - A physician's order dated 7/12/24, [facility's contracted] Hospice. - A facility care plan: I have a terminal prognosis related to Colon Cancer, dated 6/13/24. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to meet professional standards of quality for four Residents (#3, #62, #312 and #314), out of a total sample of 35 residents. Specifically, the facility failed to: 1.) For Resident #3, the facility failed to obtain weekly weights as ordered by a physician. 2.) For Resident #62, the facility failed to obtain and document pre and post dialysis weights per the physician orders. 3.) For Resident #312, the facility failed to obtain daily weights as ordered by the physician. 4.) Resident #314 the facility failed to change daily dressing as ordered by the physician.

Inspectors wroteBased on observations, interviews, policy review and record review, the facility failed to maintain a safe environment for three Residents (#82, #23, and #90) out of 35 total sampled residents. Specifically: 1. For Resident #82, the facility failed to implement the physician's order for bed alarm and floor mat. 2. For Resident #23, the facility failed to ensure nurse staff maintained 1:1 supervision in accordance with plan of care. 3. For Resident #90, the facility failed to implement the physician's order for floor mat.

Inspectors wroteBased on observation, interviews and policy review the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to: 1. Ensure inhalers and medications with shortened expiration dates are dated once opened 2. Ensure orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. 3. Ensure medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. 4. Ensure only medications of residents residing in the facility were stored in the medication cart.

Inspectors wroteBased on observation and interview the facility failed to properly store food items and properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure accurate medical records for three Residents (#3, #106 and #82) out of a total sample of 35 residents. Specifically, 1) for Resident #3 the facility failed to complete accurate skin assessments, 2) for Resident #106 the facility failed to maintain accurate medical records. 3) For Resident #82, the facility failed to accurately document the functioning of a bed alarm and presence of a floor mat 4.) For Resident #88, the facility failed to accurately document the flow rate of oxygen.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure staff followed standards and transmission-based precautions to prevent the spread of infection. Specifically: 1.) The facility failed to ensure staff wore precaution gowns when required while providing care to residents with contact precautions and enhanced barrier precautions in place on one of four nursing units. 2.) The facility failed to ensure the nurse cleaned the top of an insulin vial prior to drawing up insulin.

Inspectors wroteBased on observations, policy review, record review and interviews, the facility failed to provide a dignified existence for one Resident (#31) out of a total sample of 35 residents.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to keep one Resident (#64) free from verbal abuse out of a total sample of 35 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to implement the plan of care to ensure foot protection booties were in place for two Residents (#1 and #3) out of a total sample of 35 residents.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide the necessary activities of daily living (ADLs) for one Resident (#63) out of 35 total sampled residents. Specifically, the facility failed to provide the needed supervision and assistance with eating.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to provide an activity program for two Residents (#1 and #69) out of a total sample of 35 residents.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide appropriate treatment and services related to hearing for one Resident (#88) out of a total of 35 sampled residents. Specifically, the facility failed to assist Resident #88 in maintaining hearing abilities and making an appointment to replace a lost and/or broken hearing aid.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow a physician's order for air mattress settings for pressure ulcer prevention for 2 Residents (#91 and #102), out of a total sample of 35 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement interventions to prevent increased contractures for two Residents (#30 and #69) out of a total sample of 35 residents.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice one Resident (#88) out of a total sample of 35 residents. Specifically, the facility failed to follow Resident #88's physician's orders to implement the correct oxygen flow rate.

Inspectors wroteBased on interviews and record review the facility failed to provide the dietary preference for one Resident (#312) out of a total sample of 35 residents. Specifically, the facility failed to honor no pork products per resident preference.

Inspectors wroteBased on observations, record review, policy review and interviews the facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically, the facility failed to: 1.) Ensure housekeeping staff performed hand hygiene upon removal of gloves and followed manufactures guidelines for disinfectant contact time. 2.) Ensure a transmission based precaution sign was posted for one COVID-19 positive Resident (#1), out of a total sample of five Residents.