Centre Avenue Health and Rehab LLC

In the surveyor’s words

From the most serious findings on record at Centre Avenue Health and Rehab LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 18, 2023

  Based on interviews and record review, the facility failed to ensure three (#53, #16 and #33) of eight residents reviewed for accidents out of 32 sample residents received adequate supervision to prevent an accident/hazard. Resident #53 was known to be at risk for falls on admission as he had fallen at home. The facility failed to implement effective interventions. The resident fell two times on 2/17/23, with the first fall resulting in a head wound with active bleeding where the resident was sent to the emergency department for treatment and the head wound was glued. Observations revealed fall interventions were not implemented. […]

• Actual harm, isolatedF686Feb 9, 2022

  Based on resident observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#16 and #18) of five residents out of 28 sample residents. The facility failed to identify and implement pressure relieving interventions in a timely manner for Resident #16 to prevent the development of two unstageable pressure injuries. The resident was known to be at risk for skin impairment, had recently experienced a significant decline in her overall health status, and was known to be non-accepting of interventions such as heel protector booties and offloading her heels with a pillow. The resident required extensive two person assistance from staff for bed mobility. […]

• Actual harm, isolatedF550Feb 3, 2021

  Based on observations, record review and interviews, the facility failed to provide care in manner which promoted dignity and respect for four residents (#22, #71, #41 and #42) out of 21 sample residents. Resident #22, who was cognitively intact and dependent on staff for incontinence care, said she had to wait long periods of time for staff to provide her timely toileting assistance. Due to the facility failures to answer her call light timely to provide her toileting assistance, she sustained psychosocial harm from being self-conscious about the smell, she missed activities which provided her enjoyment. She had to wait for them in her mess and worried about getting infections from not being toileted timely. […]

• No harm, potential for more than minimal, widespreadF880Feb 3, 2021

  Based on observation, record review and interviews the facility failed to follow an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the transmission of disease and infection in six of six neighborhoods during a Coronavirus (COVID-19) outbreak. Specifically the facility failed to: -Ensure social distancing was performed during the vaccination clinic; -Ensure proper infection control practices were followed during wound care; -Ensure the appropriate personal protective equipment (PPE) was worn during visitation in isolation rooms; and, -Ensure hand hygiene was provided to residents during meal time. Findings include I. […]

• No harm, potential for more than minimal, patternF580Apr 18, 2023

  Based on record review and interviews, the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his/her authority, the resident's representative when there was a change of condition for three (#33, #59 and #64) of eight residents out of 32 sample residents. Specifically, the facility failed to notify the resident's physician and/or the resident's legal representative related to: -Resident #33's skin tear to the left lower extremity; -Resident #59's falls on 1/26/23 and 2/27/23; and, -Resident #64's falls on 2/20/23 and 3/9/23. Findings include: I. Facility policy and procedures The Change of Condition with Resident policy, revised on 7/7/22, was provided by the clinical services manager (CSM) #1 on 4/18/23 at 12:42 p.m. […]