Arleigh Burke Pavilion

In the surveyor’s words

From the most serious findings on record at Arleigh Burke Pavilion, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 8, 2021

  Based on observation, staff interview, and facility document review, it was determined the facility staff failed to store and prepare foods in a sanitary manner in the main kitchen. In the refrigerator a bag of chocolate chips was open to the air and did not evidence any labeling indicated when the bag was opened; in the freezer a bag of spinach tortellini and a bag of stuffed pasta shells were opened and failed to evidence a date when the bags were opened. In addition observation dishwashing machine revealed temperature never rose above 160 degrees for five runs of dishes through the machine. The findings include: Observation of the kitchen was conducted on 7/7/2021 at 6:35 p.m. accompanied by OSM (other staff member) #3, the director of dining services. […]

• No harm, potential for more than minimal, patternF757Jan 15, 2025

  Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure residents were free of unnecessary medications for five of 25 residents in the survey sample, R3, R6, R11, R22 and R18. The findings include: 1.The facility staff failed to ensure R3 was free of unnecessary medications by monitoring anticoagulant as ordered. R3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to afib (atrial fibrillation). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/3/25, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. […]

• No harm, potential for more than minimal, isolatedF623Jan 15, 2025

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide evidence of written notification of a discharge for one of 25 residents in the survey sample, Resident # 15. The findings include: For Resident #15 (R15), the facility staff did not provide the resident written notification of the reasons for his discharge when he was transferred to the hospital on 1/5/25. A review of R15's clinical record revealed he was transferred to the hospital on 1/5/25 due to declining physical status. Further review of R15's record failed to reveal evidence of written notification to the resident of the reasons for the discharge on [DATE]. On 1/15/25 at 10:20 a.m., OSM (other staff member) #1, the social services manager, was interviewed. […]

• No harm, potential for more than minimal, isolatedF625Jan 15, 2025

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide evidence that a bed hold notice was issued at discharge for one of 25 residents in the survey sample, Resident # 15. The findings include: For Resident #15 (R15), the facility staff did not provide the resident a bed hold notice when he was transferred to the hospital on 1/5/25. A review of R15's clinical record revealed he was transferred to the hospital on 1/5/25 due to declining physical status. Further review of R15's record failed to reveal evidence of a bed hold notification issued to the resident at discharge on [DATE]. […]

• No harm, potential for more than minimal, isolatedF655Jan 15, 2025

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide residents (or resident representatives) a summary of the baseline care plan for two of 25 residents in the survey sample, Residents #36, and #35. The findings include: 1. For Resident #36 (R36), the facility staff failed to provide the resident (or representative) a summary of the baseline care plan. R36 was admitted to the facility on [DATE]. A review of R36's clinical record (including the baseline care plan dated 12/9/24 and progress notes for December 2024 and January 2025) failed to reveal the facility staff provided R36 or the resident's representative a summary of the baseline care plan. […]