Totally Kids Rehabilitation Hospital - D/P SNF

In the surveyor’s words

From the most serious findings on record at Totally Kids Rehabilitation Hospital - D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF848Apr 16, 2026

  Based on interview and record review, the facility failed to ensure the arbitration agreements (a private way to settle a legal disagreement outside of a traditional courtroom) provided with the selection of a venue convenient to facility and resident (both parties) for three of three sampled residents (Residents 27, 47, and 51).This failure had the potential to limit Residents' choices and access to a fair arbitration process and impede oversight of dispute resolution outcomes. Findings:1. […]

• No harm, potential for more than minimal, patternF638Jan 9, 2025

  Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS- a facility assessment tool that consists of the resident assessment instrument (RAI) and the care area assessment (CAA) was conducted and submitted to the Centers of Medicare and Medicaid Services (CMS) in accordance with federal submission timeframes, for nine of nine residents (Residents 1, 2, 6, 21, 23, 24, 31, 38, and 42) reviewed for resident assessment. These failures resulted in inadequate monitoring of progress or decline for Residents 1, 2, 6, 21, 23, 24, 31, 38, and 42), and a lack of resident specific information to be sent to CMS for payment and quality measure monitoring. […]

• No harm, potential for more than minimal, patternF756Jan 9, 2025

  Based on interview and record review, the facility failed to ensure the pharmacists Monthly Medication Review (MRR- a review of patient medications by a pharmacist aimed at optimizing the health outcomes of residents) was reviewed in a timely manner for two of 50 residents dated October 1, 2024, through October 31, 2024, when the facility failed to implement a policy and procedure (P&P) that included timelines and steps to be followed once the MRR was received. This failure resulted in a delay of two months in physician review of the MRR recommendations provided by the pharmacist and had the potential for an urgent recommendation to go unnoticed, that could have resulted in residents' harm. […]

• No harm, potential for more than minimal, patternF880Jan 9, 2025

  Based on observation, interview and record review, the facility failed to ensure infection control practices were developed and maintained for two of 20 sampled residents (Residents 7 and 10) when: 1. Enhanced Barrier Precautions (EBP - extra steps taken to prevent the spread of germs to vulnerable residents during close contact care by wearing gowns and gloves) were not implemented when providing wound care for one resident (Resident 10). 2. Sterile technique (the use of practices that restrict microorganisms in the environment and prevent contamination of the field) was not followed during urinary catheterization (procedure where a thin, flexible tube called a catheter is inserted into the urethra to drain urine from the bladder) for one resident (Resident 7). 3. […]

• No harm, potential for more than minimal, patternF638Jan 12, 2024

  Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS- a facility assessment tool that consists of the resident assessment instrument (RAI) and the care area assessment (CAA)) assessment was completed and submitted to the Centers of Medicare and Medicaid Services (CMS) in accordance to federal submission timeframes, for four of four residents (Residents 41, 14, 8, and 21) reviewed for resident assessment. These failures resulted in inadequate monitoring of Residents 41, 14, 8, and 21's progress and decline, and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: 1. […]