Allbridge Rehabilitation and Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 7, 2024

  Based on observation, record review, and resident and staff interview, the facility failed to ensure the safety of Resident #34, who obtained access to a locked employee breakroom to utilize a facility microwave unsupervised. Actual harm occurred on 02/28/24 when Resident #34 sustained second degree burns to his left thigh after spilling hot water on his leg. The injury was a result of Resident #34 entering an employee breakroom with a Styrofoam cup of water where he proceeded to heat the water in the facility microwave without supervision. Upon exiting the breakroom the resident spilled the cup of hot water on his left thigh resulting in second-degree burns (a type of burn that affects the first and second layer of skin. […]

• No harm, potential for more than minimal, widespreadF851May 21, 2025

  Based on staff interview and document review the facility failed to timely submit at least quarterly the Payroll Based Journal (PBJ) staffing information for quarter one of 2025 to Centers for Medicare and Medicaid Services (CMS). This affected all 39 residents in the building. Findings include: Review of the PBJ Staffing Data Report [NAME] Report 1705 run date 05/08/25 for quarter one of 2025 (10/01/24 to 12/31/24) revealed the facility failed to submit staffing data for the quarter. Interview with Regional Director of Clinical Operations #119 on 05/20/25 at 02:34 P.M. verified corporate did not report their PBJ staffing. The corporate was under the assumption they did not have to report until they had their first star rating after their first annual survey.

• No harm, potential for more than minimal, widespreadF880May 21, 2025

  Based on interview, review of personnel files, review of the tuberculosis (TB) risk assessment, and review of facility policies the facility failed to fully complete the TB risk assessment and failed to test staff according to their TB risk assessment. This had the potential to affect 39 of 39 residents residing in the facility. Findings include: Review of the facility's TB risk assessment worksheet, dated 04/01/25 revealed under risk classification the facility put 'not applicable' next to how many inpatient beds are in your inpatient setting? They did not indicate how many patients with TB they had encountered in the last year and did not indicate their risk level. The facility indicated healthcare workers would be tested for TB upon hire and annually. […]

• No harm, potential for more than minimal, widespreadF921May 21, 2025

  Based on observation and staff interview, the facility failed to maintain and sanitary and homelike environment. This had the potential to affect the 39 of 39 residents residing in the facility. Findings include: 1. 05/21/25 from 1:46 P.M. to 1:52 P.M. tour of the facility with Regional Director of Dietary Services #124 revealed the following: a. The hallway tile has a dark build up around the wall and the floor. b. room [ROOM NUMBER] has a dark build up around the tile and the wall in the room and bathroom and a rusty colored build up around the commode. Patches of paint missing on the wall in the bathroom. The door into the room, bathroom and door jams with the paint scuffed. c. The hand rail scuffed in the hallway outside of the kitchen entrance. d. […]

• No harm, potential for more than minimal, patternF644May 21, 2025

  Based on staff interview and record review, the facility failed to have accurate diagnoses on the pre-admission screening and resident review (PASARR) when submitted. This affected four of four (Resident #11, #20, #26 and #31) residents reviewed for PASARR. The facility census was 39. Findings include: 1. Review of Resident #20's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included encephalopathy, diabetes, chronic kidney disease, alcohol abuse, dementia, restlessness and agitation, depression and mixed anxiety, delirium and psychotic disorder with hallucinations. Review of the PASARR dated 11/10/24 revealed no dementia or psychiatric diagnoses. On 05/20/25 at 10:00 A.M. […]