Trend Health & Rehab of Carthage LLC

Inspectors wroteBased on record review, resident interviews, staff interviews, and facility policy review, the facility failed to ensure residents' right to privacy in receiving mail by opening packages addressed to two (2) of 2 residents reviewed for mail privacy (Residents #29 and #72) without the residents' permission or presence, and failed to protect residents' right to receive personal mail unopened, as evidenced by concerns voiced during Resident Council that staff opened residents' mail prior to delivery. This had the potential to affect all residents who received mail at the facility.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure residents' advance directives were maintained in their medical records and readily accessible to staff for two (2) of 20 sampled residents. Resident #5 and Resident #46. Staff interviews confirmed that advance directives for some residents were maintained in admission packets in the business office rather than in the medical record, limiting staff access.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to ensure medications were properly labeled, dated, and stored for one (1) of two (2) medication rooms (South Hall) and one (1) of two (2) medication carts reviewed (North Hall).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide food at palatable temperatures for two (2) of three (3) days of survey with the potential to affect all residents who receive meals from the dietary department.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to provide reasonable accommodation of Residents' needs by not ensuring that necessary supports were consistently accessible and available to assist Residents in communicating their needs for one (1) of twenty (20) sample Residents. Resident #5.

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to ensure Activities of Daily Living (ADLs) were provided in accordance with physician orders for one (1) of two (2) residents reviewed for ADLs. Resident #54.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that resident grievances voiced through the Resident Council were thoroughly investigated, addressed, and resolved for three (3) of three (3) residents reviewed for grievances (Residents #1, #2, and #3). Findings Included:Record review of the facility policy Resident and Family Grievances/Complaints revealed Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal.12. The facility will make prompt efforts to resolved grievances .A record review of Resident Council Minutes, dated 11/20/25, revealed that residents complained that food on the weekend has gotten bad. There was no documentation that the complaint had been addressed by the facility. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure Resident #1 received necessary care and services in accordance with physician orders when staff did not obtain and implement a nephrologist's order to increase Lasix. This was identified for one (1) of three (3) residents reviewed for quality of care (Resident #1).

Inspectors wroteBased on record review, observations, interviews, and facility policy review, the facility failed to ensure a resident's right to be free from abuse and neglect as evidenced by: 1) the facility failed to prevent verbal and physical abuse by a Certified Nursing Assistant (CNA) of Resident #2, and 2) failed to prevent neglect of a resident who required transfer via a mechanical lift (Resident #1), for two (2) of three (3) residents reviewed for abuse. Findings Include: Review of the facility policy titled, Abuse Policy and Procedure, dated 04/02/24 and signed by CNA #6, revealed, Each resident of this facility has the right to be free from verbal, sexual, physical and mental abuse .neglect . [...]

Inspectors wroteBased on interviews, record reviews, and facility policy and procedure reviews, the facility failed to thoroughly investigate the incident of a fall from a mechanical lift for Resident #1 who sustained an injury to her forehead and a fracture requiring surgical repair for one (1) of three (3) residents reviewed. Cross reference F600, F656, F689 Findings Include: The facility's undated policy titled Abuse Policy Responsibility stated, The facility will identify and INVESTIGATE all suspicious or allegations of abuse (such as suspicious bruising of residents, neglect or misappropriation of resident property). The facility will review the occurrence, pattern, and trend that may constitute abuse. The facility will thoroughly INVESTIGATE all alleged violations under the direct supervision of the Administrator. [...]

Inspectors wroteBased on interviews, record reviews, and facility policy and procedure reviews, the facility failed to implement the care plan for transfer with a mechanical lift. During the transfer, Resident #1 fell from the lift and sustained a head injury and hip fracture requiring surgical repair. Resident #1 was one (1) of three (3) residents reviewed for care plans. Findings Included: Review of the facility policy titled Following the Care Plan Policy dated 2011, revealed, It is the Policy of this facility to follow a written and approved care plan for each resident. All employee will be trained upon hire and be required to follow the care plan. All employees will follow the written care plan that is developed in order to assure the residents needs are met . Review of the facility policy dated revised 6/13 titled Nurse Aide Information Policy revealed: [...]

Inspectors wroteBased on observation, interviews, record reviews, and facility policy and procedures review the facility failed to avoid a preventable accident when Resident #1 was transferred with a mechanical lift without the required two (2) person transfer assistance. This resulted in Resident #1 sustaining an injury to her forehead and a right intertrochanteric femoral fracture requiring surgery. Resident #1 was transported to the hospital emergency room (ER) two times related to the accident. This was for one (1) of three (3) residents reviewed. Resident #1 Findings Included: Review of the facility policy, undated, titled: Modified Lifting Policy read: PROCEDURE: 1. Use of a mechanical lift requires two (2) nursing assistants to perform the procedure each time that it is used. 2. Staff will follow the documented lifting protocol deemed appropriate for each resident. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review the facility failed to accurately complete section H of the Minimum Data Set (MDS) assessment for a Resident, as evidenced by incorrectly coding Indwelling catheter usage during the 7-day observation look-back period for one (1) of three (3) residents with indwelling catheters.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for a resident requiring mouth care for one (1) of 16 care plans reviewed. Resident #47 Findings Include: Review of the facility policy titled Following the Care Plan Policy undated, revealed Policy: It is the Policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan . Record review of the Care Plan for Resident #47 revealed Focus: I require assistance with ADL's (activities of daily living) r/t (related to) self-care impairment due to Left-sided hemiplegia following a CVA (Cerebral Vascular Accident) Interventions . Provide mouth care/brush teeth every shift . [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide oral care for a resident receiving enteral nutrition as evidenced by dry, crusty areas of skin on the upper and lower lips for one (1) of five (5) residents receiving enteral feedings. Resident #47 Findings Include: Review of the facility policy titled Mouth Care Policy with a revision date of January 2002, revealed Policy: It is the policy to provide oral care assistance each am (morning) and HS (bedtime) for all residents and PRN (as needed) . An observation of Resident #47, on 5/13/2024 at 11:51 AM, and again at 2:20 PM, revealed his upper and lower lips were cracked and dry with a crusty yellowish scaling of the skin. [...]

Inspectors wroteBased on resident interview, staff interviews, and record review the facility failed to promote a residents right to make choices significant to the resident for one (1) of five (5) residents reviewed for Resident Rights. Resident #1.

Inspectors wroteBased on resident interview, staff interviews, record review, and facility policy review, the facility failed to provide resident centered activities for one (1) of five (5) residents reviewed for activities.

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to implement comprehensive care plans for four (4) of twenty residents care plans reviewed. Resident #11, Resident #32, Resident #61 and Resident #67. Findings Include: A review of the facility's Following the Care Plan Policy, dated 3/21/22, revealed, it is the policy of this facility to follow a written and approved care plan for each resident .All employees will follow the written care plan that is developed in order to assure the resident's needs are met. Resident #11 Record review of Resident #11's care plans revealed the following care plan; printed date 1/4/23 revealed, Focus: I have a physical function deficit related to: [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to perform physician ordered weekly body audits as evidenced by two (2) high risk residents developing an avoidable facility acquired pressure ulcer for two (2) of 10 residents with pressure ulcers reviewed. Resident #32 and Resident #67.

Inspectors wroteBased on observation, staff interview, facility policy review, and record review the facility failed to prevent the possibility of food borne illness as evidenced by improper thawing of raw chicken, improper storage of two (2) bags of opened flour, and black substance on the inner door panel of the ice machine. This had the potential to affect 77 of 88 residents who receive food or ice from the kitchen.

Inspectors wroteBased on resident/resident representative and staff interviews, facility policy review, and record review the facility failed to resolve a grievance related to transportation to the dialysis center for one (1) of three (3) dialysis residents reviewed. Resident #25.

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to provide a resident or resident representative with a written notification for the reason of transfer/discharge to the hospital for one (1) of two (2) residents reviewed.

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to provide services to meet professional standards as evidenced by failure to check percutaneous endoscopic gastrostomy (PEG) tube placement prior to peg tube medication administration for one (1) of six (6) residents observed during medication administration. Resident #137.

Inspectors wroteBased on observations, staff interview, record review and facility policy review, the facility failed to ensure residents who were dependent on staff for nail care received those services as evidenced by long, jagged nails on two (2) of nineteen residents reviewed.

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to post Oxygen in Use signs on the room doors of resident's using oxygen for two (2) of 10 residents reviewed. Resident #11 and #187.

Inspectors wroteBased on observation, staff interview, facility policy review, and record review the facility failed to prevent the likelihood of infection as evidenced by failure to use a barrier when administering eye drops for one (1) of six (6) residents observed during medication pass, Resident #1.