Prosper Health and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600Mar 1, 2023

  Based on interview, record review, and policy review, the facility failed to ensure 1 of 4 sampled residents, Resident #2, was free from verbal abuse and neglect. Staff A, Registered Nurse (RN), verbally abused Resident #2 on 01/14/23 at about 1:00 AM, as witnessed by four staff (Staff D, Registered Nurse (RN); Staff G, RN; Staff H, Licensed Practical Nurse (LPN); and Staff I, Certified Nursing Assistant (CNA)), and overheard by the Director of Nursing via phone. The facility also neglected to provide ordered pain medications for approximately 13 hours as per staff interviews (staff verbalized Resident #2 was admitted [DATE] at 12:30 PM and staff verbally said she received pain medication on 01/14/23 at about 2:00 AM but not documented) or approximately 17 hours as per documentation (the… […]

• No harm, potential for more than minimal, patternF558Apr 4, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF693Apr 4, 2024

  Based 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). The findings included: 1) Resident #100 was admitted to the facility on [DATE] to 02/12/24 and most recently readmitted to the facility on [DATE] after being sent out to the hospital for pulling out her Peg tube. According to the resident's most recent full assessment, a 5-day Minimum Data Set (MDS), dated [DATE], Resident #100 had a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF726Apr 4, 2024

  Based 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. The findings included: 1) Review of the policy Oxygen Administration revised 12/2023 documented, General Guidelines: 1. […]

• No harm, potential for more than minimal, patternF657Jan 6, 2023

  Based on record review, interview, and policy review, the facility failed to ensure care plan meetings were completed timely and/or with participation by the interdisciplinary team (IDT), such as the Certified Nursing Assistant (CNA) and residents for 8 of 23 sampled residents reviewed for care plans meetings (Residents #13, #53, #6, #27, #17, #36, #49, and #81). The findings included: A review of the policy, titled, Social Services Guidelines - Documentation, revealed, in part, The interdisciplinary care conference is the culmination of the care planning process and is held in conjunction with MDS (Minimum Data Set) activity. […]