Bridgewalk on Harden Health and Rehabilitation, LL

In the surveyor’s words

From the most serious findings on record at Bridgewalk on Harden Health and Rehabilitation, LL, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 11, 2023

  Based on observations, interviews, record review, physician interview, and facility policy review, the facility failed to protect residents right to be free from neglect, to ensure one Resident (#1) out of 17 residents who required one-person assistance with self-feeding, was provided care and assistance to prevent a burn injury during meal service time. The facility neglected to provide care and service during a meal to a vulnerable resident who had known physical limitations, tremors, and visual impairments. Resident #1 suffered second-degree burns resulting in pain and injury to her subcutaneous chest tissue, and permanent body disfigurement related to scarring as a result of the facility's neglect to ensure safety during meal service. […]

• Immediate jeopardy, isolatedF689Oct 11, 2023

  Based on observations, interviews, record review, physician interview, and facility policy review, the facility failed to ensure one Resident (#1), out of 17 residents who required one-person assistance with self-feeding, were free from hazards during meal service. The facility's failure to ensure this resident's safety during meal service, and failure to monitor hot beverages to prevent burns, and failure to educate staff on safe food re-heating practices, and failure to ensure vulnerable residents were assessed and supervised during meals, resulted in injury to Resident #1. On 09/18/23 Resident #1, who required one-person physical assistance and supervision for eating, was served hot coffee that had been reheated in a microwave and not tested for safe serving temperature. […]

• Actual harm, isolatedF656Dec 7, 2022

  Based on observations, interviews, and record review the facility failed to develop and implement a Person-Centered Care Plan related to Activities of Daily Living (ADL) care for four (Resident #1, #6, #9, #12) of six residents sampled for care plans out of a total sample of 12 residents. Resident #6 did not have a care plan indicating the level of assistance needed with ADL's. Resident #6 was assisted with bathing by one staff person resulting in a fall, transfer to a higher level of care, and sutures. Findings included: 1. On 12/06/22 at 9:30 a.m., Resident #6 was observed lying in his bed in his room, wearing a hospital gown. […]

• Actual harm, isolatedF689Dec 7, 2022

  Based on observation, interview, and record review the facility failed to provide supervision to prevent a fall resulting in injury requiring sutures and transfer to a higher level of care for one (#6) of four residents reviewed for bathing out of a total sample of 12 residents. Findings included: Observations of Resident #6 on 12/06/22 at 9:30 a.m. revealed he was lying in his bed in his room, wearing a hospital gown and had a sutured laceration on his head open to air and a left-hand laceration, between his thumb and first finger, with sutures in place open to air. Resident #6 had numerous discolored and open areas on both arms as well as on his nose. He stated the aide took him to the shower in the shower bed. The side rails were up on the shower bed. […]

• No harm, potential for more than minimal, widespreadF851Jan 25, 2024

  Based on interview, and record review, the facility failed to submit staffing data through the Center for Medicare/Medicaid (CMS) Payroll-Based Journal (PBJ) system for the Fiscal Year Quarter 4 of 2023. Findings: Review of the Certification and Survey Provider Enhanced Reports for Quarter 4 of 2023 revealed the facility failed to submit data for the quarter. On 1/24/24 at 4:22 PM, the Scheduling Coordinator stated she and the Human Resources Director were responsible for completing and submitting the PBJ report. She explained she attempted to submit the Quarter 4 report but received many error messages which she attempted to correct but did not complete on time. She indicated the report was due on 11/14/23 and stated the Administrator was aware of the issue. […]