Advanced Healthcare Center

In the surveyor’s words

From the most serious findings on record at Advanced Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Feb 22, 2021

  Based on medical record review, staff interview, observation of the facility emergency crash carts, review of the emergency crash cart supply check list, review of the facility policy for Cardio-Pulmonary Resuscitation (CPR), and review of the recommended technique for providing CPR, the facility failed to adequately monitor the emergency crash cart supplies, ensuring a CPR backboard was available. Additionally, the facility staff failed to provide adequate life saving measures for one resident (#64) who was in [MEDICAL CONDITION] and had a Full Code status. […]

• Immediate jeopardy, isolatedF760Feb 22, 2021

  Based on medical record review, interviews with facility staff and the physician group, review of the medication reference information, and review of the facility policy for medication administration, the facility failed to ensure residents were free from significant medication errors when one resident (#64) was given scheduled insulin five hours past the scheduled administration time. This resulted in Immediate Jeopardy and serious life-threatening harm for Resident #64 when the resident received long acting and short acting insulin past the scheduled administration time, became hypoglycemic (low blood sugar) requiring intervention from the nursing staff, and experienced [MEDICAL CONDITION] requiring lifesaving measures. […]

• Actual harm, isolatedF697Aug 24, 2022

  Based on observations, medical record review, family and staff interviews, and review of facility policies, the facility failed to provide pain management to a resident experiencing pain. Actual Harm occurred when Resident #35, with a history of chronic pain, experienced pain as evident by moaning, grunting, and thrashing head on pillow throughout wound care every time one of his lower extremities was moved and grimacing and gritting teeth as range of motion was completed on lower legs. No pharmacological or non pharmacological interventions were offered to alleviate the pain. This affected one (#35) of five residents reviewed for pain. The facility census was 57. Findings include: Review of Resident #35's medical record revealed an admitted [DATE]. […]

• Actual harm, isolatedF686Jul 19, 2022

  Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure recommended interventions were implemented to prevent skin breakdown. Actual harm occurred when Resident #49 was discovered with an in-house acquired deep tissue injury to the right heel. This affected one (#49) of three residents reviewed for skin breakdown in a facility census of 57. Findings include: Medical record review revealed Resident #49 admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed the resident had severe cognitive impairment. […]

• Actual harm, isolatedF686Sep 2, 2021

  Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to obtain treatments for pressure ulcers upon admission, failed to implement pressure reducing interventions, and failed to provide ongoing monitoring and assessment of pressure ulcers. This resulted in actual harm when one resident (#1) developed two avoidable in-house Stage II pressure ulcers to the buttocks, did not have ongoing monitoring of current pressure ulcers, and did not have a treatment provided to existing pressure ulcers for six days following admission. This deficient practice affected one (#1) of three residents reviewed for skin breakdown. The facility identified two residents with current pressure ulcers. […]