Inglemoor Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Inglemoor Rehabilitation and Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF558Jul 1, 2025

  Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 2 of 23 residents (Residents #14, #39) call bells were within reach and able to use to accommodate the residents' needs. This deficient practice was evidenced by the following: 1. On 6/16/25 at 10:20 AM, While conducting the initial tour of the facility, the surveyor observed Resident #39 in their room, sleeping in bed, with the call bell hanging, on the floor, and not within the reach if of the resident. […]

• No harm, potential for more than minimal, isolatedF582Jul 1, 2025

  Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notice for 1 of 2 residents reviewed for Beneficiary Protection Notification, (Resident #141). This deficient practice was evidenced by the following: On 6/23/25 at 8:49 AM, the surveyor reviewed the Skilled Nursing Facility (SNF) Beneficiary Protection Notification (SNFBPN) Review completed by the facility for Resident #141 as followed: -The SNFBPN Review indicated Resident #141 last covered Medicare A day was 2/21/25, and Resident #141 remained in the facility. The SNFBPN Review further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) form was not given to Resident #141. […]

• No harm, potential for more than minimal, isolatedF607Jul 1, 2025

  Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire for 1 of 6 newly hired licensed staff reviewed, Staff Member #1, in accordance to facility's policy. The deficient practice was evidenced by the following: On 6/17/25 at 9:40 AM, the surveyor requested ten randomly selected newly hired employee files from the Director of Nursing (DON). On 6/17/25 at 1:18 PM, after a brief review of the facility provided files which did not contain any documented license verification, the surveyor asked the DON to provide the surveyor the initial license verification documentation for each of the newly hired employees. […]

• No harm, potential for more than minimal, isolatedF641Jul 1, 2025

  Based on interview and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for 1 of 23 residents (Resident #75) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: A review of the Centers for Medicare & Medicaid Services (CMS's) Resident Assessment Instrument (RAI; helps facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Version 3.0 Manual, October 2024, reflected in SECTION I: ACTIVE DIAGNOSES . […]

• No harm, potential for more than minimal, isolatedF655Jul 1, 2025

  Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to develop a baseline care plan for a newly admitted resident who received a psychotropic medication (med), specifically an antipsychotic med for 1 of 5 residents reviewed for unnecessary medications (Resident #191). This deficient practice was evidenced by the following: A review of Resident #191's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), bipolar disorder (a disorder associated with episodes of mood swings… […]