Smith Ranch Skilled Nursing & Rehabilitation Cente
Inspection Findings
F-Tag F688
F-F688).
Findings:
During a review of the facility's Restorative Program Monthly Audit, dated 5/1/25, the Restorative Program Monthly Audit was completed for the month of April 2025. The Restorative Program Monthly Audit indicated
a total of 84 missed visits from 13 Residents reviewed.
During a review of the facility's Order Listing Report, dated 5/15/25, the Order Listing Report indicated there are a total of 22 Residents currently receiving RNA services.
During an interview on 5/16/25 at 11:16 a.m. with the Director of Nursing (DON) and Director of Rehabilitation (DOR), The DOR stated the DON oversees the RNA program because it falls under nursing and the DOR is only responsible for training staff and putting in RNA orders. The DOR further stated she does not complete any auditing for the RNA program. The DON stated he quickly scans the RNA weekly progress notes but does not verify the treatment provided against the orders. The DON and the DOR both confirmed they were unaware of any issues with the RNA program not fulfilling the physician orders.
During a concurrent interview and record review on 5/16/25 at 1:01 p.m. with the Administrator (Admin) and
the DON, the QAPI Meeting Minutes dated October 2024 to April 2025 were reviewed. The minutes indicated no focus on the RNA program. The Admin confirmed QAPI did not identify any concerns with the RNA program.
During a review of the Facility's Quality Assurance Performance Improvement Plan (QAPIP), undated, the QAPIP indicated, Segments of Care . Inpatient Rehabilitation . Services Rendered . Provide appropriate levels of rehabilitation to the inhouse Residents and coordinate with their MD's [Medical Doctor] . Clinical care will be measured through: Consultant evaluations and feedback of practice, MDS-QI [Minimum Data Set Quality Improvement- an assessment tool used to guide resident care] scores, Family/Resident survey scores, QAPI tools .
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 555595