Inspection Reports for Estates Healthcare & Rehab Center

The facility was found deficient in ensuring accurate resident assessments for mood and behavior, proper respiratory care including safe storage of oxygen and CPAP equipment, and maintaining an effective infection prevention and control program. Several residents' assessments were inaccurate, respiratory equipment was improperly stored, and lapses in environmental sanitation were observed.

The facility failed to ensure appropriate treatment and care according to orders and resident preferences, specifically failing to monitor a resident who refused dialysis treatments. Additionally, the facility failed to implement an effective infection prevention and control program, including improper use of personal protective equipment and inadequate communication regarding infectious diseases.

The complaint investigation was substantiated. The facility failed to prevent a physical altercation between Residents #8 and #9 resulting in injury, failed to prevent verbal abuse of Resident #1 by a CNA, failed to timely report abuse allegations, and failed to comply with PASRR requirements. Immediate jeopardy was identified but corrected prior to the survey.

The facility failed to protect residents from abuse, including physical and verbal abuse, and failed to provide adequate supervision to prevent resident-to-resident altercations. The facility also failed to timely report abuse allegations and failed to incorporate PASRR recommendations into care planning and documentation. Immediate jeopardy was identified related to resident safety and supervision but was corrected prior to the survey.

The complaint investigation revealed substantiated abuse incidents involving staff and residents, a resident-to-resident altercation, and failure to prevent a fall due to removal of safety equipment. The facility took corrective actions including staff termination, re-education, and monitoring.

The facility failed to protect residents from abuse, including verbal and physical abuse between residents and staff, failed to prevent an accident involving a resident who fell from a van lift after anti-tippers were removed from his wheelchair, and failed to maintain accurate documentation and adherence to physician orders regarding administration of PRN pain medications for two residents.

The complaint investigation involved allegations of neglect, failure to notify physician of change in condition, failure to provide timely wound care, failure to prevent falls and injuries, failure to prevent elopement, failure to provide dialysis communication, failure to provide pharmaceutical services, and failure to provide specialized rehabilitative services. Substantiation status is not explicitly stated.

The facility failed to immediately notify the physician of a significant change in Resident #67's condition, failed to report and investigate neglect related to Resident #67's fall in a transport van, failed to provide timely wound care resulting in prolonged wound drainage and discomfort, failed to prevent Resident #99's elopement from the secured unit, failed to ensure dialysis communication forms were received for Residents #9 and #63, failed to maintain accurate narcotic logs and remove expired medications on the 300 hall medication cart, failed to label and date insulin vials properly, and failed to provide speech therapy evaluation for Resident #2 as ordered.

The complaint investigation was triggered by an incident where Resident #67 fell backwards in a wheelchair during transport by an outside provider, hitting his head and sustaining injuries. The facility failed to timely report the incident to the State Survey Agency and failed to investigate and report the results of the investigation. Interviews with staff and the resident confirmed the incident and failures in reporting and investigation.

The facility failed to timely report suspected abuse and neglect of Resident #67, who fell backwards in a wheelchair without anti-tippers or brakes during transport, hitting his head and sustaining injuries. The Administrator did not report the incident to the State Survey Agency. Additionally, the facility failed to investigate and report the results of the neglect allegation. The transport van driver did not properly secure the resident, and the facility's policies and procedures for event reporting were not followed.

The complaint investigation found that CNA A provided care alone to Resident #1, who required two staff members for assistance. This led to the resident falling during a bed bath and sustaining a right femur fracture. The immediate jeopardy began and ended on 12/05/24, with corrective actions taken before the survey. The CNA was suspended and re-educated, and staff were re-trained on care requirements and use of the documentation system.

The facility failed to ensure adequate supervision and assistance for Resident #1, who required two staff members for care. A CNA bathed the resident alone, leading to a fall and a right femur fracture. The facility identified immediate jeopardy, corrected the issue before the survey, and re-educated staff on safe patient handling and use of the care documentation system.

The facility failed to develop and implement comprehensive person-centered care plans with measurable outcomes for residents, specifically failing to monitor and document signs and symptoms of dehydration and urine output for Resident #1. Additionally, the facility failed to ensure medication carts were locked when unattended, posing a risk of unauthorized access to medications.

The investigation was complaint-driven, focusing on call light accessibility for Resident #2 and accident prevention for Resident #1. The complaint was substantiated with findings of minimal harm and risk to residents.

The facility failed to ensure Resident #2 had reasonable accommodation for call light accessibility, placing residents at risk of unmet needs. Additionally, the facility failed to provide adequate supervision and safety measures to prevent accidents for Resident #1, who fell from bed without fall mats on both sides, risking injury.

The complaint investigation substantiated that Resident #1 sustained a burn blister on her left wrist on 08/09/24 after spilling hot coffee due to wearing gloves that caused her to lose grip of the cup. The resident did not notify staff immediately as she did not feel pain initially. The facility treated the burn and implemented corrective measures including staff in-service and temperature monitoring.

The facility failed to ensure adequate supervision and assistance to prevent accidents, resulting in one resident sustaining a burn blister from hot coffee. The facility had policies and procedures for serving coffee at safe temperatures and had re-inserviced staff after the incident. The burn was treated with physician-ordered ointment and dressings, and the facility took corrective actions including audits and staff training.

The facility failed to ensure razors were kept out of residents' reach in one shower room, posing a risk of injury. Additionally, the facility did not have a registered nurse serving as Director of Nursing on a full-time basis for 53 of 65 days reviewed, risking inadequate care and services.

The complaint investigation found that the facility did not retrieve or follow up on hospital discharge documents for Resident #1, resulting in missed follow-up care. Interviews with staff including LVN A, CNA B, the ADON, and the Administrator confirmed the failure to notify the physician or arrange follow-up visits as recommended by hospital discharge instructions.

The facility failed to follow hospital discharge orders for Resident #1, resulting in missed follow-up appointments with a primary care physician. This failure placed the resident at risk for worsening conditions and inadequate care after a fall-related hospital visit.

The facility was found deficient in multiple areas including failure to respect resident dignity by improperly using a WanderGuard device, failure to notify physicians of significant changes in resident health, incomplete care plans, failure to ensure residents received needed vision services, improper medication storage, inadequate infection control practices, and unsafe patient care equipment.

The complaint investigation found substantiated abuse and neglect involving Resident #3 physically assaulting Resident #2 on 08/24/23 and Resident #1 on 12/08/23, causing serious injuries including subdural hematoma and fractures. The facility failed to provide adequate supervision and interventions despite Resident #3's known aggressive behavior. Immediate jeopardy was identified on 12/08/23 but was corrected before the survey began.

The facility failed to protect residents from abuse and neglect, specifically failing to prevent Resident #3 from physically assaulting Resident #2 and Resident #1, resulting in serious injuries to Resident #1. The facility had inadequate supervision and interventions for Resident #3 despite his history of aggression. Immediate jeopardy was identified but corrected prior to the survey.

The complaint investigation substantiated that LVN A verbally abused Resident #1 on 08/04/23. The abuse was witnessed by CNA B and the SLP. LVN A was reassigned to a different hall following the investigation. Resident #1 reported feeling bad about himself after the interaction. LVN A admitted to raising her voice but denied telling the resident he should not be in the nursing home.

The facility failed to ensure Resident #1 was free from verbal abuse by LVN A, who was found to have spoken to the resident in a belittling and unprofessional manner. The investigation confirmed the incident through interviews with Resident #1, CNA B, SLP, LVN A, and the DON, resulting in LVN A being reassigned to reduce contact with the resident.

The facility failed to ensure that medication carts were locked and secured when unattended, as evidenced by an unlocked medication cart on the 400 Hall left unattended for approximately 4 minutes. This posed a risk for drug diversion or theft. Interviews with nursing staff and administrators confirmed the expectation that medication carts must be locked when not in use.

The facility failed to ensure that medication carts were locked and secured when unattended, as evidenced by an unlocked medication cart on the 400 Hall left unattended for approximately 4 minutes. Interviews with nursing staff and administrators confirmed the expectation that medication carts must be locked to prevent drug diversion or theft.

The complaint investigation focused on medication administration errors involving Resident #61, specifically missed doses of Clonazepam and Lyrica due to medication unavailability and delayed reordering. It also addressed the failure to maintain a working call light system for Resident #42, which had been non-functional for over a month, limiting his ability to call for help.

The facility failed to provide pharmaceutical services ensuring timely administration of medications for Resident #61, resulting in missed doses of Clonazepam and Lyrica over multiple days. Additionally, the facility failed to maintain a working call system for Resident #42, preventing him from requesting staff assistance.