Embassy Rehab and Care Center

In the surveyor’s words

From the most serious findings on record at Embassy Rehab and Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 4, 2023

  Based on clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 2 of 2 residents reviewed for elopement (Residents #39 and #18). The facility's failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of January 17, 23 on April 18, 23 at 12:58 p.m. The Facility Staff removed the Immediate Jeopardy on April 19, 23 through the following actions: a. The facility engaged an additional keypad door alarm on the North Door. The door alarm sound is loud and heard throughout the facility. […]

• Immediate jeopardy, patternF805May 4, 2023

  Based on observations, clinical record review, resident and staff interviews and facility policy review the facility failed to assure that resident received the recommended therapeutic menu for residents at risk for choking for 5 of 5 residents reviewed (Residents #8, #6, #13, #22, and #27). This failure increased the risk of residents choking or aspirating (something entering the lungs), therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of April 24th at 3:45 P.M. The Facility Staff removed the Immediate Jeopardy on April 25, 2023 through the following actions: 1. […]

• Actual harm, isolatedF686May 4, 2023

  Based on observation, clinical record, facility policy, and staff interview, the facility failed to provide care consistent with professional standards of practice, to prevent pressure ulcers and provide necessary treatment and services to promote the healing of a pressure ulcer, prevent an infection for 1 of 1 resident reviewed (Resident #16). The facility reported a census of 38 residents. The MDS assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• Actual harm, isolatedF684Apr 26, 2022

  Based on observations, clinical record reviews, policy reviews, staff, and physician interviews, the facility failed to implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to assure thorough completed weekly skin assessments for residents with an identified skin impairment for 1 of 1 resident reviewed (Resident #20). Resident #86 admitted to the facility on [DATE] from an acute care hospital following a fall at home that resulted in a fractured lower leg. […]

• Actual harm, isolatedF686Apr 26, 2022

  Based on observations, clinical record review, facility policy review, staff interviews, and Wound Clinic Registered Nurse interview the facility failed to ensure the residents received care consistent with professional standards of practice, to prevent pressure ulcers, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 2 residents reviewed for facility acquired pressure ulcers (Residents #11 and #23). Resident #23 admitted to the facility on [DATE] following acute hospitalization for [CONDITION(S)] to the lower extremities. On 12/8/21, the facility identified Resident #23 had a Stage III pressure ulcer to the left buttock. On 12/15/21, the Wound Clinic identified three additional pressure areas in which the facility failed to identify and assess. […]