Tri State Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF678Sep 26, 2024

  Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure a resident's end of life wishes were honored and failed to identify staff were not appropriately trained and certified in Cardio-Pulmonary Resuscitation (CPR) before performing CPR for 4 residents (Resident #3, #8, #9, and #10) of 5 residents reviewed for Cardio-Pulmonary Resuscitation (CPR) and code status. The facility failed to ensure staff followed Resident #3's end of life wishes and failed to ensure staff were trained and certified before performing CPR on Resident #8 on [DATE], Resident # 9 on [DATE], and on Resident #10 on [DATE].The facility failed to ensure staff were educated and knowledgeable when Certified Nursing Assistants (CNAs) and… […]

• Immediate jeopardy, patternF726Sep 26, 2024

  Based on facility policy review, job description review, medical record review, employee time punch review, and interview, the facility failed to provide competent and proficient nursing staff to assure resident safety an attain or maintain the highest practicable level of wellbeing of residents when nursing staff failed to honor the end of life wishes, failed to ensure nursing staff were knowledgeable of a code status, met specific competency requirements, and understood their job responsibilities related to Cardio-Pulmonary Resuscitation (CPR), Do Not Resuscitate (DNR) Status, and life saving measures for 4 of 5 residents (Resident #3, #8, #9, and #10) reviewed for CPR. […]

• Immediate jeopardy, patternF835Sep 26, 2024

  Based on facility policy review, job description review, facility document review, Quality Assurance and Performance Improvement (QAPI) Plan review, QAPI Meeting Minutes review, and interviews, the facility's Administration failed to provide effective leadership and oversight after 1 resident's (Resident #3) end of life wishes were not honored and 4 staff members who were not trained or certified in Cardio-Pulmonary Resuscitation (CPR) and life sustaining measures performed CPR on 3 residents (Residents #8, #9, and #10) from ,d+[DATE]-,d+[DATE] of 5 residents reviewed for CPR. The facility's Administration failed to identify the non-compliance and develop and implement effective processes through the facility's Quality Assurance and Performance Improvement (QAPI) committee. […]

• Immediate jeopardy, patternF837Sep 26, 2024

  Based on facility documentation review, facility policy review, job description review, and interview, the facility's Governing Body failed to identify non-compliance and implement effective corrective action plans through the facility's Quality Assurance and Performance Improvement (QAPI) program, failed to provide effective leadership and oversight to the facility and the facility's administration to ensure all nursing staff, including Certified Nursing Assistants (CNAs), were educated on the code or Cardiopulmonary Resuscitation (CPR) process when Resident #3's end of life wishes for Do Not Resuscitate (DNR) were not honored on [DATE], when CPR was performed on 3 residents (Residents #8, #9, and #10) from [DATE] through [DATE] by 4 CNAs who were not trained or certified in CPR life… […]

• Immediate jeopardy, patternF867Sep 26, 2024

  Based on facility document review, facility policy review, job description review, Quality Assurance and Performance Improvement (QAPI) Plan review, QAPI Meeting Minutes review, and interviews, the facility's QAPI committee failed to ensure an effective QAPI program that identified quality deficiencies, implement performance improvement activities to address quality concerns, and perform a root cause analysis related to residents' code status', end of life wishes, and staff performing Cardio-Pulmonary Resuscitation efforts who were not trained or certified in CPR. […]