Alcester Care And Rehab Center, Inc

In the surveyor’s words

From the most serious findings on record at Alcester Care And Rehab Center, Inc, in the surveyor’s own words.

• Actual harm, patternF700Jun 6, 2023

  Based on incident report review, interview, observation, record review, and policy review, the provider failed to: *Properly measure the bedrail safety zones for eleven of eleven residents with bedrails (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11), which resulted in resident injury for one of one sampled resident (11) when his head got wedged in an area of the bedrail that had not been measured. *Complete assistive device assessments for three of eleven sampled residents with bedrails (1, 3, and 9). *Obtain informed consent for the use of a bedrail for one of eleven sampled residents (3) with bedrails. *Update care plans to reflect the use of bedrails for four of eleven sampled residents (3, 8, 10, and 11). […]

• Actual harm, isolatedF760Nov 4, 2021

  Based on interview, record review, and policy review, the facility failed to ensure one of one resident (33) received a new order for antipsychotic medication to treat aggressive behaviors resulting in harm to others. Findings include: 1. Review of progress notes for resident 33 in the closed electronic medical record (EMR) revealed a pattern of increasingly aggressive behaviors: *On 9/16/21, resident is resistive with repositioning/transfers and yells out at that time. *On 9/24/21, continues to resist and yells out with transfers and repositioning. *On 9/26/21, the resident was seen kicking and swinging at another resident. *On 9/27/21, hitting at staff with clinched fists when turning resident in bed. […]

• No harm, potential for more than minimal, widespreadF727Mar 9, 2023

  Based on interview and staff schedule review the provider failed to ensure a registered nurse (RN) had been scheduled for eight hours of coverage for two of four weekends in February 2023. Findings include: 1. Interview and staff schedule review on 3/9/23 at 11:00 a.m. with director of nursing (DON) B revealed she: *Had worked full time Monday through Friday completing Minimum Data Set (MDS). *Was available to staff by phone twenty-fours hours per day seven days per week. 2. Interview and staff schedule review on 3/09/23 at 12:43 p.m. with administrator A regarding RN coverage revealed: *She had been aware that they did not have eight hours per day of RN coverage seven days per week. *She was attempting to hire an RN.

• No harm, potential for more than minimal, widespreadF880Mar 9, 2023

  A. Based on observation, interview, and policy review, the provider failed to ensure appropriate disinfection after resident use for of one of one whirlpool and furnishings in the one of one tub room by one of one certified nursing assistant (CNA) E. Findings include: 1. Observations on 3/7/23 at 11:19 a.m. and 3:59 p.m. of the whirlpool room revealed: *The door to the room was open. A sign on the door stated to keep the door locked. *A stack of towels was setting on top of a short gray plastic storage cabinet against the right wall inside the room. The towels were out in the open and uncovered. *A reception-style chair was positioned against the right wall beside the storage cabinet with towels laid out on the seating surface of the chair. […]

• No harm, potential for more than minimal, widespreadF657Nov 4, 2021

  Based on observation, interview, record review, and policy review, the facility failed to revise the care plans to address: *The use of physical devices to reduce the risk of falls for three of four sampled residents (20, 21, and 33). *Communication needs and discharge plan for one of one sampled resident (18). *Behavior symptoms for one of three sampled residents (33). *The use of bed rails for one of six sampled resident (25) with bed rails. *Risk of accidents related to wandering for one of three sampled residents (33). *The use of assistive devices with transferring for one of one sampled resident (22). *Pressure ulcer healing for one of one sampled resident (25). Findings include: 1. Observation on 11/2/21 at 9:00 a.m. […]