Focused Care at Allenbrook

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare and distribute food in accordance with professional standards for food safety in that -The facility failed to ensure that dented cans were not stored with undented cans. The facility failed to ensure that one of 2 refrigerators in the dining room was free from expired food products. These failures placed residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the status for one (Resident #10) of 18 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #10's annual MDS assessment accurately reflected her lack of natural teeth in her oral cavity. This failure could place residents at risk for receiving inadequate care and services due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rates were not 5 percent or greater. During medication administration, a medication error rate of 7 percent was identified (2 errors out of 28 opportunities). These errors involved 2 of 9 residents (resident #20 and resident #52) and 1 of 2 MA (MA J) administering medications. 1. The facility failed to ensure that MA J did not attempt to administer divalproex sodium 500mg oral tablet to Resident #20 during the morning medication pass, when the physician's order indicated the medication was to be administered at bedtime. 2. The facility failed to ensure that MA J did not administer zinc sulfate oral tablet to Resident #52 when the physician's order specified zinc sulfate oral capsule resulting in administration of medication in a form inconsistent with the prescribed order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment remained as free from accidents as possible and that each resident received adequate supervision and assistance to prevent accidents for 1 of 30 residents (Resident #2) reviewed for adequate supervision. The facility failed to provide adequate supervision and put measures in place to prevent residents from eloping. Resident #2 had a history of exit seeking behaviors and wandering from his previous facility and eloped from this facility in 1/7/25. He was found by a good Samaritan in his wheelchair across the street from the facility. This noncompliance was identified as Past Non-Compliance. The IJ began on 1/7/2025 and ended on 1/8/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. -The facility failed to label, and date left over food items stored in the walk-in cooler. -The facility failed to ensure dented cans were not stored together with undented cans. These failures could place residents at risk for food contamination and foodborne illness due to cross contamination.

Inspectors wroteBased on interview and record review the facility failed to conduct a comprehensive assessment of a resident in accordance with the timeframes, within 14 calendar days after admission, excluding readmission in which there is no significant change in the resident's physical or mental condition and not less than once every 12 months for 1 of 18 residents (Resident #47) reviewed for comprehensive annual assessments. The facility failed to ensure Resident #47's Annual MDS Assessment was completed within 14 days of the ARD. This failure could place residents at-risk of not having their assessments completed timely, which could result in denial of services and or payment for services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessments accurately reflect the resident's status for 1 of 5 residents (Resident #24) reviewed for accurate assessments. The facility failed to ensure Resident #24's MDS accurately reflected the resident's falls. This failure could place residents at risk for not receiving needed services or receiving improper or incorrect care and services necessary for their physical, mental and psychosocial well-being.

Inspectors wroteBased on interviews and record review, the facility failed to were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening Based on interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for reviewed for 2 of 3 residents (Resident #47 and Resident #25) reviewed for resident assessments. The facility failed to update the PASRR Level 1 forms for Resident #47 and Resident #25 to indicate mental health illness. This failure could place residents at risk of not having their special needs assessed and met by the facility.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure that resident received treatment and care in accordance with professional standards of practice for CR#1 reviewed for quality of care. The facility failed to monitor and ensured CR#1 received proper dressing changes on the Intra right jugular Vein (Central Line) on CR#1's neck. The facility failed monitor and ensured CR#1 received proper dressing changes on CR#1's Cholecystectomy tube. This deficient practice could affect residents by diminishing their quality of care. Findings Included: Record review of CR #1's undated Face Sheet reflected she was admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female with the following diagnoses: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent falls for 1 (Resident #1) of six residents reviewed for accidents, hazards, and supervision. The facility interventions did not prevent 18 unwitnessed falls and 16 witnessed falls with multiple injuries and hospitalization. The facility failed to implement the physician order for a use of a helmet to prevent injuries from falls. Facility staff, the NP and the Rehab Director were unaware of this physician order. These failures placed residents who are dependent on staff for activities of daily living, supervision, and bed mobility at risk of not being adequately supervised, no adequate intervention, not putting appropriate devices in place, worsening of existing wounds, decline in quality of care, and experiencing pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen: -The facility failed to ensure that the kitchen floors were clean and free of food particles. -The facility failed to ensure that food preparation equipment was clean and free of grease build up. -The facility failed to ensure food items in the refrigerator\freezer were dated, labeled, and appropriately sealed. These failures placed all residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident maintained acceptable nutritional status, such as usual body weight or desirable body weight, unless the resident clinical condition demonstrated this was not possible, for 1 of 6 residents (Resident #62) reviewed for nutritional status, in that; Resident #62 who admitted to the facility with poor nutrition was not provided prompt intervention to prevent severe weight loss of -16.85 pounds in 6 months. This failure could affect all residents in the facility with weight loss at increased risk of weight loss.

Inspectors wroteBased on interview, observation and record review the facility failed to revise the comprehensive care plan for 1 of 6 residents (Resident #62) reviewed for care plans in that: Facility failed to revise Resident #62's care plan to have assistance with feeding during each meal. This failure could place all residents at risk of not having their individually needs met and place them at risk of not receiving proper nutrition.

Inspectors wroteBased on interview and record review the facility failed to ensure a post-discharge plan of care was developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment and the post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services for 1 of 4 residents (CR # 1) reviewed for an effective discharge process. The facility failed to complete a discharge summary prior to and after CR#1's discharge. This failure could place residents at risk for incorrect, incomplete, or misleading information recorded regarding discharged residents and failures in the continuity of care for residents.