Rogers Health and Rehabilitation Center

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the rear casters on the mechanical lift remained unlocked during lifting a resident to allow for stabilization, and to prevent injuries or tipping affecting 1 (Resident #41) of 1 sampled resident reviewed for lift.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the kitchen walls, tiles, air vents, and door frames were maintained in good repair and were free of chips, stains and rust; baseboards were secured and were maintained in clean sanitary conditions; and dietary staff washed their hands before handling clean equipment for 2 of 2 meals observed.

Inspectors wroteBased on interview and record review, the facility failed to ensure Advance Directive documents were maintained in a section of the resident's medical record readily retrievable by facility staff for 4 (Residents #9, #26, #27 and #32) of 18 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the privacy of 2 (Residents #12 and #32) of 8 (Residents #1, #12, #18, #27, #32, #39, #43 and #46) sampled residents who resided on C Hall.

Inspectors wroteBased on observation and interview, the facility failed to ensure 3 (rooms [ROOM NUMBER]) of 12 rooms on the E Hall were free of damage.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fingernails were maintained to promote good hygiene for 1 (Resident #22) of 15 (Residents #1, #7, #9, #12, #22, #26, #27, #32, #33, #35, #36, #46, #47, #52 and #211) sample mixed residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders were followed when administering medication and enteral nutrition for 1 (Resident #32) of 2 (Residents #32 and #47) sampled residents with percutaneous endoscopic gastrostomy (PEG) tubes, and failed to ensure medications were given in the recommended time frame for 2 (Residents #29 and #37) of 31 residents that had medications administered by Licensed Practical Nurse #3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician to minimize the potential for hypoxia or other respiratory complications for 1 (Resident #22) of 9 (Residents #1, #6, #8, #20, #21, #22, #27, #39 and #52) sample residents according to a list provided by the Administrator on 11/30/23 at 10:52 AM.

Inspectors wroteBased on interview and record review the facility failed to ensure sufficient qualified nursing staff were available at all times to meet the needs of the residents in a timely manner. This failed practice had the potential to affect all 58 Residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure full-time nursing assistants have become certified within 4 months of nurse aide training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was free of significant medication errors for 1 (Resident #35) of 2 (Residents #35 and #57) residents that were observed during the 8:00 AM medication administration pass.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with the provision of nail care and ensuring call devices were readily available for residents. These failed practices had the potential to affect all 58 residents who resided in the facility as identified on a Census Report provided by the Administrator on 11/30/2023 at 03:45 PM.

Inspectors wroteBased on interview and record review, the facility failed to maintain a designated Infection Preventionist who was responsible for the facility's Infection Prevention and Control Plan.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a call light was kept within the residents' reach to allow residents to request assistance for 1 (Resident #33) of 21 (Residents #1, #2, #6, #7, #8, #9, #12, #18, #20, #22, #26, #27, #32, #33, #35, #36, #39, #46, #47, #52, and #211) sampled residents who were capable of utilizing the call light system.

Inspectors wroteBased on observation and interview, the facility failed to ensure 3 (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 12 Rooms on the E Hall were free of damage.

Inspectors wroteBased on observation and interview, the facility failed to ensure the laundry room was free from standing water and trash for 1 of 1 laundry room.

Inspectors wroteBased on interview, and record review, the facility failed to implement the individualized plan of care on 1 (Resident #2) of 1 Resident.

Inspectors wroteBased on record review and staff interview, the facility staff failed to prevent a resident from falling out of bed during a bed bath, for 1(Resident #2) of 4 (Resident #1, #2, #3 and #4) sampled case mix residents reviewed for accidents.

Inspectors wroteBased on observation and inteview, the facility failed to provide a sanitary environment for staff and residents, by failing to clean and eliminate black substances, replace ceiling tiles, and clean the air vent in a Resident's room and the nurses' station. This failed practice has the potential to affect all residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness; failed to ensure 1 of 1 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages; failed to ensure leftover food items were used properly to maintain food quality, and failed to ensure meal trays were served using proper hand hygiene for residents who received meals and meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 68 residents who receive meals from the kitchen per NPO (no food by mouth) list provided by Administrator#1 8/29/22.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set [MDS] assessments were completed accurately to reflect necessary care and services for 2 (Resident's #40 and #71) of 2 sampled residents to provide accurate information for developing a plan of care to meet the residents' needs. This failed practice had the potential to affect 73 residents, according to the Resident Matrix provided by Administrator #2 on 08/29/22.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fingernails were maintained to promote good hygiene for 1 (R# 30) of 16 (R #6, #8, #14, #15, #16, #22, #28, #30, #35, #36, #37, #47, #53, #55, #58, #63) of the sampled case mix residents who were dependent on staff for Diabetic Nail Care according to a list provided by the Administrator on 09/02/22 at 07:30am and failed to ensure bathing was provided as scheduled for 1 (R#41) of 10 (R #14, #15, #36, #50, #55, #57, #62, #66, & #71) who were dependent on staff for bathing according to a list provided by the Administrator on 9/1/22 at 12:35 PM.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a call light was kept within residents' reach to allow residents to request assistance to accommodate their individual care needs for 1 (Resident #72) of 12 (R #3, #15, #24, #28, #29, #30, #47, #57, #62, #66, #71, #72) sampled residents who were dependent on staff assistance and were capable of utilizing the call light system.

Inspectors wroteBased on record review and interviews the facility failed to employ a qualified Social Worker with a minimum of a bachelor's degree, to meet the needs of the residents. This failed practice had the potential to affect all 73 residents who resided in the facility.