Medallion Post Acute Rehabilitation

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Construction Deficiencies

Install a two-hour-resistant firewall separation.

Egress Deficiencies

Have exits that are accessible at all times.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

A survey prompted by complaint #CO39948 was completed on 4/22/25. One deficiency was cited. Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for one (#2) of three residents out of nine sample residents.Resident #2, who had a history of falling and previous fractures that included a burst fracture of the thoracic vertebra (bone in the upper spine caused by trauma), was admitted to the facility on 10/9/24.On 2/11/25 at 6:45 a.m. Resident #2, who ambulated independently with her walker, slipped and fell while walking to the bathroom. After the fall, Resident #2 was heard yelling. A licensed practical nurse (LPN) went to check on the resident and found her lying on her left side, complaining of 8 out of 10 pain, on a 1 to 10 pain scale, to her left shoulder and left hip. According to the LPN' s documentation of the fall, Resident #2 refused to allow nursing staff to remove her clothing for a skin evaluation and she requested to be transported to the hospital at that time.The LPN notified the director of nursing (DON), who was the registered nurse (RN) on-call, to notify her of his findings, which included Resident #2' s complaints of 8 out 10 pain to her left shoulder and left hip. Resident #2 was assisted into a wheelchair by the LPN and a certified nurse aide (CNA). The 2/11/25 at 6:50 a.m. nursing progress note, written by the DON, documented a RN assessment conducted by the DON, based on the findings reported from the LPN on-site at the time of the resident' s fall. It indicated Resident #2 had slipped and fallen while ambulating to the bathroom. It documented Resident #2 was able to move all extremities without injury or noted deformity. It documented Resident #2 was to be transported to the hospital after Resident #2 and Resident #2' s representative insisted the resident be evaluated at the hospital.-However, there was no RN in the facility at the time of the fall to conduct a hands-on physical assessment of the resident. Resident #2 was moved off the floor and into a wheelchair, despite her complaints of significant pain, refusal to remove her clothes f..

A complaint survey, prompted by #CO39617, #CO39619, Incident #39453, and Incident #39455 was completed on 4/22/25. One deficiency was cited. Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for one (#2) of three residents out of nine sample residents.Resident #2, who had a history of falling and previous fractures that included a burst fracture of the thoracic vertebra (bone in the upper spine caused by trauma), was admitted to the facility on 10/9/24.On 2/11/25 at 6:45 a.m. Resident #2, who ambulated independently with her walker, slipped and fell while walking to the bathroom. After the fall, Resident #2 was heard yelling. A licensed practical nurse (LPN) went to check on the resident and found her lying on her left side, complaining of 8 out of 10 pain, on a 1 to 10 pain scale, to her left shoulder and left hip. According to the LPN' s documentation of the fall, Resident #2 refused to allow nursing staff to remove her clothing for a skin evaluation and she requested to be transported to the hospital at that time.The LPN notified the director of nursing (DON), who was the registered nurse (RN) on-call, to notify her of his findings, which included Resident #2' s complaints of 8 out 10 pain to her left shoulder and left hip. Resident #2 was assisted into a wheelchair by the LPN and a certified nurse aide (CNA). The 2/11/25 at 6:50 a.m. nursing progress note, written by the DON, documented a RN assessment conducted by the DON, based on the findings reported from the LPN on-site at the time of the resident' s fall. It indicated Resident #2 had slipped and fallen while ambulating to the bathroom. It documented Resident #2 was able to move all extremities without injury or noted deformity. It documented Resident #2 was to be transported to the hospital after Resident #2 and Resident #2' s representative insisted the resident be evaluated at the hospital.-However, there was no RN in the facility at the time of the fall to conduct a hands-on physical assessment of the resident. Resident #2 was moved off the floor and into a wheelchair, despite her complaints of significant pain, refusal to remove her clothes f..

A complaint survey, prompted by #CO39189, Incident #38948, #38950 and #39238 was conducted on 2/12/25 to 2/13/25. One deficiency were cited. Based on record review and interviews, the facility failed to ensure one (#1) of three residents at risk for elopement out of seven sample residents received adequate supervision and were kept free from elopement.Specifically, the facility failed to provide Resident #1 the supervision necessary to prevent elopement. The facility failures created a situation with serious harm and a situation of likelihood of serious harm to residents' health and safety if not immediately corrected.Resident #1, diagnosed with metabolic encephalopathy (improper brain function due to underlying medical condition), unspecified psychosis (mental condition caused by loss of contact with reality), dementia and anxiety, eloped from the facility on 2/1/25 at an unknown time. Facility staff were unaware Resident #1 was missing until after 6:00 a.m. on 2/2/25 when certified nurse aide (CNA) #2 began answering call lights at the start of her shift. At approximately 6:20 a.m. on 2/2/25, CNA #2 noticed Resident #1' s dinner tray, untouched, in the resident' s room. Resident #1' s roommate reported to CNA #2 she had not heard Resident #1 in the room since approximately 5:30 p.m. on 2/1/25, the previous day. CNA #2 reported this to a nurse on duty and the assistant director of nursing (ADON) was notified at approximately 6:30 a.m. A full facility check was conducted, the staff checked the surrounding neighborhood and the resident was unable to be located. At 8:10 a.m. the admissions coordinator (AC) informed the interdisciplinary team (IDT) that Resident #1 had been located at a local hospital.The facility began investigating the incident immediately after Resident #1 was discovered in care of the local hospital and determined Resident #1 eloped from the facility after CNA #1 and licensed practical nurse (LPN) #1 failed to monitor Resident #1 every two hours per facility protocol and due to Resident #1' s refusal to wear a wanderguard.Findings include:Observations, interviews and record review confirmed the facility corrected the deficient practice prior to th..