Daughters of Miriam Center for Nursing & Rehabilit

In the surveyor’s words

From the most serious findings on record at Daughters of Miriam Center for Nursing & Rehabilit, in the surveyor’s own words.

• Actual harm, isolatedF684Nov 8, 2024

  Based on medical record review, review of witness statements, review of facility incident investigation, review of the medical examiner report, review of the police report, and review of the facility policy, the facility failed to ensure timely injury identification and physician notification and treatment following a fall with fracture for Resident #162. Actual Harm occurred on [DATE] 4:30 P.M. when the facility failed to obtain timely and appropriate imaging (x-ray) for Resident #162 following a fall with injury resulting in a delay in treatment. Following the fall, the resident complained of increased pain, had swelling, an abrasion to the knee and was unable to stand. On [DATE] at 3:15 P.M a new order was written for an x-ray of the area. X-ray results on [DATE] at 9:15 P.M. […]

• Actual harm, isolatedF686Nov 8, 2024

  Based on record review, interview, and review of the facility policy, the facility failed to assess Resident #163's wound and obtain appropriate treatment orders upon re-admission from the hospital and failed to complete pressure ulcer treatments as ordered by the physician or nurse practitioner to prevent a decline in the wound resulting in suspected osteomyelitis (serious bone infection). Actual Harm occurred on 10/02/24 when Resident #163's pressure ulcer progressed from a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) measuring 1.5 centimeters (cm) by 2.0 cm with a depth of 0.1 cm to an… […]

• Actual harm, isolatedF689Nov 8, 2024

  Based on observation, record review, policy review and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program to prevent falls, ensure falls were thoroughly investigated and/or ensure residents were safely transferred. Actual harm occurred on 10/03/24 at approximately 11:40 P.M. when Resident #19, who was cognitively impaired, was at high risk for falls and had a history of fall and required substantial or maximal staff assistance for activities of daily living (ADLs), sustained an unwitnessed fall that resulted in displaced fractures of the right seventh through 12th ribs and a non-displaced sternal fracture. […]

• No harm, potential for more than minimal, widespreadF803Nov 8, 2024

  Based on record review, observation and interview, the facility failed to ensure all menu items were prepared in advance and menus and/or substitutions were followed for resident meal service. This had the potential to affect all 159 residents receiving meals from the kitchen excluding the seven residents (#44, #46, #97, #110, #111, #137, and #315) the facility identified as receiving nothing by mouth (NPO). The facility census was 166. Findings include: 1. Review of the facility menu for 10/30/24 lunch revealed the meal was to consist of tomato soup, grilled cheese on Texas toast, potato chips, oven roasted vegetables and banana cake. […]

• No harm, potential for more than minimal, widespreadF804Nov 8, 2024

  Based on observation, interview, and food committee meeting minutes review, the facility failed to ensure palatable and appealing meals were served. This had the potential to affect all residents receiving meals from the kitchen. The facility identified seven Residents (#44, #46, #97, #110, #111, #137, and #315) as receiving nothing by mouth (NPO). The facility census was 166. Findings include: 1. Interview on 10/30/24 at 1:26 P.M. with Dietary Director (DD) #813 revealed he had identified an issue with meal timeliness and keeping good temperatures. DD #813 indicated it would be easier and faster to serve from the pantry on each unit. DD #813 indicated the new facility ownership had changed the process from serving from the pantry to serving from the main kitchen. […]