Roman Eagle Rehabilitation and Health Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF919Mar 8, 2023

  Based on observations, interviews, and document review, the facility staff failed to ensure two (2) common bathrooms were equipped with a call system. These two (2) bathrooms were located near the lobby area of the facility; one had a sign reading MEN and the other had a sign reading WOMEN. The findings include: On 3/6/23 at 3:10 p.m., it was observed that a common bathroom with a sign reading MEN was not equipped with a call system. This bathroom was unlocked and accessible to residents, staff, and visitors. This bathroom was able to be locked from the inside. On 3/6/23 at 4:19 p.m., it was observed that a common bathroom with a sign reading WOMEN was not equipped with a call system. This bathroom was unlocked and accessible to residents, staff, and visitors. […]

• No harm, potential for more than minimal, isolatedF658Mar 8, 2023

  Based on observation, staff interview, facility document review and during a medication pass and pour the facility staff failed to follow professional standards of practice for the administration of medications. The findings included: During a medication pass and pour observation, the facility staff crushed medications and administered together for 2 of 6 Residents, Resident #140, and Resident #77 Surveyor observed licensed practical nurse (LPN) #2 on 03/07/23 during a medication pass and pour at 8:20 am. LPN #2 prepared medications (4 medications) for Resident #140, crushing all medications together, placing in ice cream and administering together. […]

• No harm, potential for more than minimal, isolatedF760Mar 8, 2023

  Based on observation, staff interview, clinical record review, facility document review and during a medication pass and pour the facility staff failed to ensure 1 of 38 residents was free from significant medication errors, Resident #140. The findings included: For Resident #140 the facility staff crushed and administered the non-crushable medication potassium chloride (KCl). Resident #140's face sheet listed diagnoses including but not limited to hypokalemia, hypertension, and anxiety. Resident #140's most recent minimum data set with an assessment reference date of 01/25/23 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. […]

• No harm, potential for more than minimal, isolatedF761Mar 8, 2023

  Based on observation, staff interview, facility document review and during a medication pass and pour the facility staff failed to ensure medications were stored in a secure manner for 1 of 9 medication carts. The findings included: Facility staff failed to secure medications during a medication pass and pour. Surveyor observed licensed practical nurse (LPN) #2 on 03/07/23 during a medication pass and pour. LPN #2 removed a medication bin from the medication cart, placed it on top of the medication cart and prepared resident's medication. After preparing medication, LPN #2 entered resident's room, leaving the medication bin on top of the medication cart, and leaving cart unlocked. Upon returning to the cart, LPN #2 replaced the bin in the cart. […]

• No harm, potential for more than minimal, isolatedF842Mar 8, 2023

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to maintain a complete and accurate clinical record for 2 of 38 residents, Resident #389 and #110. The findings included: 1. For Resident #389, the facility nursing staff failed to accurately document in the clinical record for the medication Xanax. Resident #389's diagnoses included, but were not limited to, generalized anxiety disorder and major depressive disorder. There was no completed minimum data set (MDS) assessment for this resident. Resident #389's clinical record included an order for Xanax 0.5 mg by mouth three times a day for generalized anxiety disorder. […]