Braden River Rehabilitation Center LLC

Inspectors wroteBased on interviews and record review the facility failed to file a grievance for one resident (#1) out of three residents reviewed for grievances.

Inspectors wroteBased on observations and interviews, the facility did not ensure a sanitary and homelike environment for four out of five units.

Inspectors wroteBased on observations, and staff interviews, the facility failed to ensure cooked and prepared food was stored in a manner to prevent food contamination during four of four meal observations observed on 9/23/2024, 9/24/2024, 10/1/2024 and 10/2/2024.

Inspectors wroteBased on observation, record review, and interview, the facility failed to file and follow-up on a grievance regarding Activities of Daily Living (ADL) care for one (#91) of five residents sampled.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed accurately for three (#93, #38, #60) of twenty-nine residents sampled.

Inspectors wroteBased on observations, interviews and medical record review, the facility failed to ensure the revision and accuracy of care plan problem areas for two (#16, #91) of 55 sampled residents.

Inspectors wroteBased on observations, staff and resident interviews, and medical record review, the facility failed to provide grooming and personal hygiene assistance to one (#198) of four residents reviewed for activities of daily living (ADL's).

Inspectors wroteBased on observation, interview,and record review, the facility failed to ensure a hazard free environment for one (#400) of six residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one resident (#43), diagnosed with dementia, the treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being out of two residents sampled for dementia care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5.00%. 29 medication administration opportunities were observed, and three errors were identified for two residents (#7 and #85) out of three residents observed. These errors constituted a 10.34% medication error rate. Findings Included: During medication administration on 10/2/24 at 8:39 a.m., Staff E, Licensed Practical Nurse (LPN) was observed preparing and administering the following medications to Resident #85. The medications included: [...]

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to ensure an injury of an unknown source resulting in physical injury and subsequent death, were reported to the proper authorities within the prescribed timeframes for 1 (#1) of 3 residents reviewed.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure accurate documentation for dispensing and administration of controlled substances for two residents (Resident#15 and #16) of two residents sampled for pain medication administration.

Inspectors wroteBased on observation, interview and medical record review the facility failed to ensure the request for an outside medical procedure was honored for one residents (#44) out of two sampled residents in a timely manner.

Inspectors wroteBased on observations, interviews and medical record review the facility failed to ensure reasonable accommodations were provided to maintain independence for assistance related to the use of the call light for one resident (#14) out of five residents reviewed for limited range of motion.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure devices, braces, or splints for contracture prevention were provided as ordered for one resident (#333) out of six sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure care and services were in place for an indwelling catheter for one resident (#236) out of four residents with indwelling catheters.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure physician orders were followed related to fluid restrictions for one resident (#129) out of nine sampled residents.

Inspectors wroteBased on observation, interviews, medical record reviews, and policy review the facility failed to ensure 1. respiratory care and services was consistent with professional standards of practice for two residents (#99 and #111) out of two residents with tracheostomies, and 2. failed to ensure care and services were in place for oxygen therapy for one resident (#236) out of ten residents receiving oxygen therapy in the facility.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to complete Dialysis Communication forms for one resident ( #129) out of the sampled five residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to post current an accurate nurse staffing data at the beginning of each shift for two days (7/23/22 and 7/24/22) of three days.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure behavioral and side effect monitoring was conducted with the use of psychotropic medications for two residents (#233 and #84) of five residents sampled for unnecessary medications.

Inspectors wroteBased on observation, record review and interview the facility failed to honor resident rights for seven (Residents #18, 33, 35, 38, 68, 84, and 94) of nine residents that smoked were denied the right to smoke and three (Residents #4, 19, and 69) of six residents were denied the right to have privacy during medication administration.

Inspectors wroteBased on observations, staff interviews and medical record review, the facility failed to ensure care plans were developed and interventions implemented for four (#104, #177, #89, and #175) of 56 sampled residents related to 1. Ensuring fall floor mats were placed appropriately when the resident was in bed, 2. Development of a care plan related to dialysis treatment, and 3. Implementation of interventions related to weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an accident free environment for one (Resident #97) of eight residents sampled. The facility failed to ensure the area surrounding Resident #97's bed was clear of tripping hazards related to floor mats being placed to both sides of Resident #97's bed, and the floor mats were placed without objects stored on top of them.

Inspectors wroteBased on record review and interview the facility failed to ensure that each dialysis resident received dialysis services consistent with standards of practice for one (Resident #89) of three residents related to communication and follow up between the facility and the dialysis center.

Inspectors wroteBased on observations, staff interview and record review, the facility failed to ensure medications were stored appropriately and supervised as given for one (Resident #17) of fifty-six sampled residents as evidence by nursing staff leaving cup with pills/tablets on the resident's over the bed table without ensuring that the resident took the medication.

Inspectors wroteBased on observations, staff interview and facility record review, the facility failed to ensure kitchen equipment to include one of one walk in freezer maintained and free from heavy ice crystallization and ice build up. It was determined that large chunks of ice were forming in and around where food was stored.