Achieve Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Achieve Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Jan 11, 2025

  Based on interview, record review, and review of facility policy, the facility failed to accurately document Resident (R)110's wishes to be a full code; and failed to periodically review code statuses for R110, for 1 of 36 sampled residents reviewed for code status. This failure placed the resident at risk of not receiving life saving measures. On [DATE] at 8:56 PM, the Administrator was notified that the failure to accurately reflect a residents code status in the medical record, in accordance with the resident's wishes, constituted Immediate Jeopardy at F578. On [DATE] at 8:56 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. […]

• Immediate jeopardy, isolatedF689Mar 7, 2024

  Based on the review of the facility policy, observations, and interview, the facility failed to ensure that Resident (R)1 was free from elopement from the facility on February 27th, 2024, at approximately 5 PM. On 03/06/2024 at 4:11 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 03/06/2024 at 4:11 PM, the survey team provided the Administrator and Interim Director of Nursing with a copy of the CMS Immediate Jeopardy (IJ) Template at F689 related to 42 CFR 483.25 - Quality of Care, Informing the facility IJ existed as of 02/27/2024 for failure to ensure that Resident (R)1 was free from elopement from the… […]

• Immediate jeopardy, isolatedF760Mar 7, 2024

  Based on review of the facility policy, record review, and interviews, the facility failed to administer medications according to medication practices for 1 of 1 Resident, Resident (R)2. R2 was given his medications whole versus crushed and the nurse did not observe the resident while administering the medications. On [DATE] at 4:11 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. […]

• Immediate jeopardy, isolatedF689Dec 15, 2023

  Based on review of facility policy, interview and record review, the facility failed to provide adequate supervision to prevent an elopement. Specifically, on 12/12/23 at approximately 8:30 AM, Resident (R)1 was found by police at a gas station approximately 3.7 miles from the facility. This failure placed R1 at risk for severe harm and/or death due to cold exposure, dehydration and/or other medical complications, or being struck by a motor vehicle. On 12/14/23 at 3:15 PM, the Administrator and the Director of Nursing were notified that the failure to prevent the elopement of Resident (R)1 constituted Immediate Jeopardy (IJ) at F689. […]

• Immediate jeopardy, isolatedF600Jun 15, 2022

  Based on review of the facility policy titled, Abuse, Neglect and Exploitation record review, interviews, and observations, the facility failed to provide adequate supervision for 1 of 3 residents reviewed for accidents related to wandering. Resident (R) 1 had a successful elopement from an unconfirmed door of the facility on 04/18/22 approximately between 2:30 PM and 3 PM. Failure to establish, maintain and implement written policies and procedures regarding abuse places an individual's health and safety at risk for serious injury, harm, impairment, or death. R1, with a history of exit seeking behaviors, was found roaming in the parking lot of the facility by Certified Nursing Assistant (CNA)10, adjacent to the highway, on 04/18/22 at approximately 2:55 PM. […]