Starr Regional Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Starr Regional Health & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Feb 6, 2024

  Based on review of facility policy, Quarterly Payroll Based Journal (PBJ) and interview, the facility failed to report PBJ for Quarter 4 2023 (July 1- September 30). The findings include: Review of the facility policy titled, Reporting Direct-Care Staffing Information (Payroll-Based Journal) showed, .Direct-care staffing and census information will be reported electronically to CMS though the Payroll-Based Journal System (PBJ) system . Review of Quarterly Payroll Based Journal (PBJ) dated 7/1/2023 - 9/30/2023 showed, .Failed to Submit Data for the Quarter . During an interview on 2/6/2024 at 9:22 AM, the Administrator confirmed the facility failed to submit the PBJ data, by the required deadline, for the fourth quarter of 2023.

• No harm, potential for more than minimal, patternF812Jun 23, 2021

  Based on observation, review of manufacture instructions, and interview the facility failed to maintain the dishwasher in the manufacture parameters for low temperature machine parameters affecting 61 of 65 residents. The findings include: Observation of the facility dishwasher revealed the following parameters posted on dishwasher: .Chemical Sanitizing .Final rinse minimum temperature 120 degrees . Observation and interview with the Assistant Dietary Manager on 6/22/2021 at 8:45 AM, of the dishwasher revealed the washer was being used as a low temperature washer with chemical sanitation. Continued observation and interview revealed the washer minimum low temperature was 120 degrees when used as a chemical machine with the current reading after 2 attempts of 110 degrees maximum. […]

• No harm, potential for more than minimal, isolatedF880Jan 14, 2026

  Based on facility policy review, medical record review, observations, and interviews, the facility failed to maintain infection control by storing oral hygiene equipment in an unsanitary manner for 2 residents (Residents #52 and #31), failed to use proper Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) for 1 resident (Resident #51), and failed to administer medications in a sanitary manner for 1 resident (Resident #6) of 54 residents reviewed in the facility.The findings include:Review of the facility's policy titled, Medication Administration ., dated 1/2018, revealed .Medications are administered as prescribed in accordance with good nursing principles and practices .Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), dated 12/2022,… […]

• No harm, potential for more than minimal, isolatedF641Feb 6, 2024

  Based on Resident Assessment Instrument (RAI) Manual, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (#46) of 27 residents reviewed. The findings include: Review of the Resident Assessment Instrument (RAI) Manual dated 10/2011 showed .The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals .the assessment process includes direct observation, as well as communication with the resident and direct care staff . […]

• No harm, potential for more than minimal, isolatedF645Feb 6, 2024

  Based on facility policy review, medical record review, observation and interview, the facility failed to ensure a level I PASSAR [Preadmission screening and resident review]was submitted for 1 resident (#25) of 5 residents reviewed for PASSAR. The findings include: Review of the facility policy titled, Screening and Resident Review (PASSARR) dated 8/2019, showed .PASRR a federally mandated advocacy process that requires that anyone who is admitted to a Medicaid-funded NF [Nursing Facility] be screened to identify the presence of serious mental illness, intellectual disability, or development disability or related condition. […]