Prosper Health and Rehabilitation Center

Inspectors wroteBased on observation, clinical and administrative record review and interview, the facility failed to ensure that residents received the necessary care and services for wound care. This is evidenced by the staff failure to provide evidence of thorough assessment when a wound is noted as open; failed to complete the weekly skin checks appropriately; failed to correctly identify skin issues in a timely manner; and failed to ensure wound care is done as prescribed and dated appropriately. This failure affected 2 of 3 sampled residents reviewed for wound care, Resident #1 and Resident #2.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide medication in a dignified manner for 1 of 4 sampled residents for dignity, Resident #51.

Inspectors wroteBased on observation, interviews, record and policy review, the facility failed to write a grievance as presented for 1 of 1 sampled resident reviewed for grievances, Resident #78.

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement written policy and procedures to prevent abuse for 3 of 3 abuse allegations affecting Residents #33, #48, #101, #86, and #38, as evidenced by lack of communication by staff to management, lack of documentation of events, and lack of documentation of notification to management, physicians and families. The census at the time of survey was 98 residents.

Inspectors wroteBased on record review and interview, the facility failed to review and revise care plans for discontinued physician orders for psychotropic medication for 2 of 28 sampled residents, Resident #6 with discontinued physician orders for antipsychotic medication, and Resident #49 for discontinuation of Transmission Based Precautions, peripherally inserted central catheter (Pic) line and antibiotics.

Inspectors wroteBased on observations, interviews, policy review and record review, the facility failed to administer scheduled medications in a timely manner for 1 of 1 sampled resident, reviewed for pain management, Resident #86, as evidenced by medications being administered outside the 60 minutes window before or after the scheduled time, unless specified by the prescriber.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to apply a resting hand splint for 1 of 1 sampled resident, Resident #3, reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure adequate monitoring for behaviors for a resident receiving a psychotropic medication for 1 of 1 sampled resident reviewed, Resident #12.

Inspectors wroteBased on observation, interview, record and policy review, it was determined the medication error rate was 8 percent (%), Two (2) medication errors were identified while observing a total of 25 opportunities, affecting Resident #19, and Resident #107.

Inspectors wroteBased on observation, interview and record review, the facility failed to secure medications for 1 of 28 sampled residents, Resident #37.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to collect urine specimen timely for 1 of 1 sampled resident, Resident #67, reviewed for Urinary Tract Infection (UTI), resulting in a delay of antibiotic treatment for the UTI.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility is administered in a manner that enables it to use its resources effectively and efficiently to ensure staff act in a manner consistent with compliance with federal, state and local laws and professional standards regarding abuse with the potential to affect 98 out of 98 residents.

Inspectors wroteBased on record review, interview and policy review, it was determined, the facility failed to report an allegation of abuse. The failure affected 1 of 2 sampled residents, Resident #1.

Inspectors wroteBased on record review and interview, it was determined, the facility failed to ensure discharge planning was implemented in a safe manner. The failure affected 1 of 2 sampled residents, Resident #1.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure proper care and services for the indwelling urinary catheters for 2 of 3 sampled residents, related to improper catheter care for Resident #1, and failure to properly anchor the indwelling urinary catheters for Residents #1 and #67, for the prevention of urinary tract infections (UTIs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of mechanical lift slings (used for the Hoyer lifts) for 7 of 12 sampled residents who require a mechanical lift for transferring (Residents #1, #18, #19, #44, #67, #89, and #100). Three of 12 sampled residents had a lift sling, but there was no name on the sling to identify it to the resident, as per the facility process (Resident #20, #23, #63). Eleven of 13 random non-sampled residents either did not have a lift sling, had one with no name on it, or had one belonging to another resident. At the time of the survey there were 24 residents who were assessed as needing the mechanical lift for transferring. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide nutrition via enteral tube feeding as ordered for 4 of 4 residents reviewed for tube feeding (Residents #100, 29, 67, 1).

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure competent nursing staff during care for 2 of 8 sampled residents observed. Staff failed to ensure an order for the use of oxygen and failed to replace an empty water bottle for the oxygen of Resident #1; failed to ensure proper order of care for the wound and tube feeding for Resident #1, failed to ensure competency for setting the tube feeding pump for Resident #1, and failed to properly administer medications through the PEG tube (feeding tube surgically placed in the stomach) for Resident #23.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the shower schedule for Resident #19 to ensure he received his 2 showers per week. And the facility failed to ensure a certified nursing assistant communicated Resident #92's desire for outside activities to the Activity Director.

Inspectors wroteBased on record review and interview, the Facility failed to provide appropriate beneficiary notices for 3 of 3 sampled residents reviewed for Beneficiary Protection Notification (Residents #58, #110, and #89).

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure timely Activities of Daily Living (ADL) care for 3 of 6 sampled residents, as evidenced by a lack of timely incontinence care for Residents #23 and #89, failure to trim a fingernail for Resident #23, and failure to ensure mouth care for Resident #1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a specialty air mattress and protective boots were provided for 1 of 2 sampled residents. Resident #1 was identified as having a facility acquired pressure injury.

Inspectors wroteBased on record review and interview, the facility failed to ensure documented provision of dialysis and ongoing communication with the dialysis facility for 1 of 1 sampled resident (Resident #55).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure complete and accurate medical records for 4 of (Residents #20, #5, #98, #53, and #55).

Inspectors wroteBased on record review and interview, the facility failed to ensure timely provision of physician ordered antibiotics for 1 of 1 sampled resident (Resident #78).

Inspectors wroteBased on clinical and administrative record review and interview, the facility failed to ensure timely completion of the Comprehensive Assessments for 2 of 3 sampled resident, Residents #2 and #3, as evidenced by lack of timely initial and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

Inspectors wroteBased on clinical and administrative record review and interview, the facility failed to provide evidence that an accurate nutritional assessment was completed for 1 of 2 sampled residents reviewed for weight loss, Resident #1, who experienced a weight loss.

Inspectors wroteBased on observation, clinical and administrative record review and interview, the facility failed to ensure the staff maintained the resident's respiratory supplies and equipment that are consistent with acceptable standards of practice and physician orders, as evidenced by the observation of multiple resident's respiratory supplies not dated, were expired or were improperly stored.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by an Interdisciplinary Team (IDT) composed of individuals with direct care knowledge of the resident and his/her needs. This impacted 1 of 2 sampled residents, Resident #1, reviewed for care plans.

Inspectors wroteBased on record review, policy reviews, and interview, the facility failed to ensure care and services were provided to 1 of 2 sampled residents, Resident #1, that included failure to implement recommended discharge instructions for follow up diagnostic studies, failure to obtain recommended consults and failure to communicate and coordinate with the resident's responsible party the changes in treatment plan; and facility staff failed to report a skin injury, and subsequently did not investigate and implement additional interventions to minimize reoccurrence for 1 of 2 sampled residents, Resident #1.

Inspectors wroteBased on observation, record review, policy review and interview, the nursing staff were unable to demonstrate competency related to the provision of nursing assessments and reporting changes in condition. This failure affected 2 of 2 sampled residents, Residents #1 and #2.

Inspectors wrote5. Review of the record reviewed Resident #17 was admitted to the facility on [DATE]. Further review revealed the most recent Minimum Data Set (MDS) assessment was completed 09/28/22. The record lacked any evidence of a care plan meeting with participation of the IDT (Interdisciplinary Team), the resident and or his representative. During an interview on 01/06/23, the Social Services Director (SSD) stated Resident #17 was scheduled to have a care plan meeting soon, in conjunction with the current quarterly assessment dated [DATE]. The SSD was asked to locate and provide evidence of the care plan meeting in conjunction with the September 2022 MDS assessment. During a subsequent interview on 01/06/23 at 12:10 PM, the SSD stated she was unable to find any evidence of a previous care plan meeting. 3. Resident #6 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable diseases and infections for 6 of 7 sampled residents, as evidenced by: Staff failed to ensure COVID-19 symptom monitoring for Residents #17, #306, #65, #53, and #355; failed to ensure proper indwelling urinary catheter maintenance and care for Residents #53 and #49; and failed to ensure an ointment belonging to another resident was not used for Resident #49.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 of 3 sampled residents were spoken to and treated in a dignified manner (Residents #303, #304, and #305).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and update care plans to reflect the status of behaviors such as combativeness, agitation and wandering; and the use of antianxiety and antibiotic medications for 1 of 23 sampled residents, Resident #36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely treatment of a fungal rash for 1 of 4 sampled residents reviewed for non-pressure ulcer skin conditions (Resident #306).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the provision of ordered pain medications for 1 of 2 sampled residents (Resident #304).

Inspectors wroteBased on record review and staff interview, the facility failed to ensure staff adequately monitored Blood Pressure and provided Blood Pressure medications as per physician-ordered parameters for 2 of 5 sampled residents reviewed for unnecessary medications (Residents #6 and #17).

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were secured for 1 of 6 medication carts, utilized by two different nurses on the 400 pod.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure posting of staffing hours daily for 6 of 9 days reviewed.