Star City Rehabilitation and Nursing

Inspectors wrote2. The facility staff failed to provide the correct amounts of food on three (3) residents' breakfast trays on the morning of 2/14/25 (Resident #2, Resident #16, and Resident #17). On the morning of 2/14/25 at 8:51 a.m., the surveyor noted Resident #17's breakfast tray did not include Large Portions which was noted under Food Likes on the resident's meal slip. The breakfast tray was noted to contain one (1) folded egg omelet, two (2) link sausages, and (2) half slices of toasted bread. On the morning of 2/14/25 at 8:54 a.m., the surveyor noted Resident #16's breakfast tray did not include Large Portions which was noted under Food Likes on the resident's meal slip. Resident #16 was ordered a mechanical soft diet. The breakfast tray was noted to contain one (1) folded egg omelet and one (1) scoop of ground sausage. [...]

Inspectors wroteBased on observations, interviews, and facility document review, the facility staff failed to employ dietary staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services of the facility.

Inspectors wroteBased on interviews and facility document review, facility staff failed to follow the facility menus to meet the daily nutritional and dietary needs of all residents that receive nutrition by oral means.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to provide nourishing snacks to residents that receive snacks by oral means that wish to eat at non-traditional times.

Inspectors wroteBased on observations, staff interviews, and facility document review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Inspectors wrote4. For Resident #3 the facility staff failed to ensure the physician's order summary was correct. Resident #3's Resident #3's clinical record listed diagnoses which included but not limited to unspecified intracranial injury with loss of consciousness, personal history of traumatic brain injury, and dysphagia. Resident #3's most recent minimum data set with an assessment reference date of 01/09/25 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Section K, Swallowing/Nutrition, coded the resident as receiving 51% or more of nutrition through tube feeding. Resident #3's comprehensive care plan was reviewed and contained a care plan for At risk of malnutrition r/t (related to) need for tube feed with NPO (nothing by mouth) diet order and The resident requires tube feeding r/t dysphagia. [...]

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the quality assurance program met the needs of the facility as evidenced by repeated deficiencies in the areas of resident rights, comprehensive resident centered care plans, food and nutrition, quality of care, and pharmacy services and failed to monitor the effects of implemented changes and make needed revisions to the action plans as needed for the prevention of further deficiencies, as evidenced by new findings (deficient practice) in the areas of quality of life, lab radiology and other diagnostic services, and administration.

Inspectors wroteBased on observation, staff interview, and facility document review the facility staff failed to ensure a clean, comfortable, homelike environment for 2 of 17 residents, Resident #3 and Resident #11.

Inspectors wroteBased on observations, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the comprehensive care plan was reviewed and revised to address the resident's dietary breakfast request for one (1) of 17 sampled residents (Resident #2).

Inspectors wroteBased on staff interviews, clinical record review and facility document review, the facility staff failed to implement an effective discharge planning process that focuses on the residents discharge goals and effectively transitions them to post discharge care for 1 of 17 residents in the survey sample, Resident #5 (R5).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a shower/bath was offered twice a week to one (1) of 17 residents (Resident #2).

Inspectors wrote2. For Resident #5 (R5) the facility staff failed to provide wound care daily per provider orders. The clinical record was reviewed. R5 was admitted with an order that read, Cleanse perineal wounds with wound wash, pat dry, pack wound with iodoform packing strips, cover with ABD pads (abdominal pads- a thick, absorbent nonadhesive dressing). Every shift. On 11/18/24, 11/20/24 night shift, there were blanks on the TAR indicating the treatments were not done. This order was discontinued on 11/23/24. On 11/23/24 an order was put in that read, Cleanse perineal wounds with wound wash, pat dry, pack wound with iodoform packing strips, cover with ABD pads. Two times a day for wound care. There were holes on the TAR for 12/9/25, 12/10/25, 12/12/25 all on day shift, 12/22/25 day shift and 12/23/25 day and night shift. This order was discontinued 12/27/25. [...]

Inspectors wroteBased on staff interviews, clinical record review, and facility document review the facility staff failed to provide treatment in accordance with provider orders to promote pressure area healing for 1 of 17 residents, Resident #9.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure medications and biologicals were stored and labeled correctly for 2 of 17 residents, Resident #3 and Resident #13.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to address lab test recommendations for one (1) of 17 sampled residents (Resident #2).

Inspectors wroteBased on observations, staff interviews, and facility document review, the facility staff failed to consistently follow menus for resident meals.

Inspectors wroteBased on observations, staff interviews, and facility document review, the facility staff failed to ensure that food was served at a safe and/or appetizing temperature.

Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, the facility staff failed to store, prepare, and serve food in accordance with professional standards for food service safety for 4 of 6 resident care units and the facility kitchen.

Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, the facility staff failed to maintain an effective pest control program for 1 of 6 resident care units (Juniper).

Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to complete a comprehensive admission assessment for one (1) of eight (8) sampled residents (Resident #1).

Inspectors wroteBased on staff interviews and clinical record review, the facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time limits for one (1) of eight (8) sampled residents (Resident #1).

Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility staff failed to follow medical provider orders for two (2) of eight (8) sampled residents (Resident #1 and Resident #3).

Inspectors wroteBased on observation, staff interview and facility document review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This requirement was not met as evidenced by the facility staff failed to discard out of date perishable food items, failed to store uncooked meat separately from other food, failed to cover, date and label perishable food items, and failed to store foods under sanitary conditions in the facility Main Kitchen and in 4 out of 4 unit kitchen service areas; Countryside (1st floor), Rainbow(1st floor), Emerald(2nd floor) and Juniper(2nd floor).

Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to provide the 2023-2024 COVID-19 vaccine to three (3) of five (5) residents sampled for immunization review, the three (3) who consented to receive the vaccine. (Resident #15, #63, and #65).

Inspectors wroteBased on interviews and document review, the facility staff failed to ensure one (1) of 19 current sampled residents were able to access personal funds deposited with the facility (Resident #15).

Inspectors wroteBased on interviews and document review, the facility staff failed to provide a resident's responsible party and the ombudsman with written information related to a discharge/transfer for one (1) of 22 sampled residents (Resident #11).

Inspectors wroteBased on interviews and document review, the facility staff failed to provide a resident's responsible party with written bed hold information for one (1) of 22 sampled residents (Resident #11).

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered care plan for 1 of 22 residents in the survey sample, Resident #54.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, facility staff failed to provide pressure ulcer dressing changes as ordered for 1 of 22 residents in the survey sample (Resident #32). Resident #32 was admitted to the facility with diagnoses which included chronic congestive heart failure, essential hypertension, chronic kidney disease, generalized muscle weakness, clostridium difficile enterocolitis, and stage 3 sacral ulcer. On the Minimum Data Set Assessment with Assessment Reference Date 1/14/24, the resident scored 15/15 on the Brief Interview for Mental Status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During initial tour on 2/7/24, the resident reported being generally happy with care with the exception of wound care. The resident reported not having wound dressings changed on 2 night shifts the previous week. [...]

Inspectors wroteBased on interviews and document review, the facility staff failed to ensure residents' drug regimen were free from unnecessary drugs for two (2) of 22 sampled residents (Resident #24 and Resident #60).

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) medication errors in 37 opportunities for a medication error rate of 5.41%. These medication errors affected Resident #291.