Englewood Post Acute and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Englewood Post Acute and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 22, 2021

  Based on record review and interviews, the facility failed to provide one (#1) of three residents, out of five sample residents, adequate supervision and an environment as free from accident hazards as possible, contributing to an accident involving harm. On 6/8/21 at approximately at 12:45 p.m., nursing staff were alerted that Resident #2 had a fall in the facility transport van during his return from his appointment. The facility failed to ensure Resident #2 was securely fastened in his wheelchair during transport to and from his appointment. […]

• Actual harm, isolatedF684Jun 6, 2023

  Based on observations, record review and interviews, the facility failed to provide needed care of services, resulting in an actual decline in physical, mental and psychosocial well-being for one (#275) out of four residents reviewed out of 33 sample residents. Resident #275, who had a severe cognitive impairment, was admitted to the facility 1/26/23. The resident did not have a medical decision maker, so the facility proceeded to implement a medical health proxy on 3/5/23. The facility failed to notify and coordinate with the health care proxy regarding the resident's care, the contact documented with the health care proxy was 5/20/23. Resident #275 had lost weight since her admission to the facility on [DATE], 21.6% in total in four months, which was considered severe. […]

• No harm, potential for more than minimal, patternF641Nov 7, 2024

  Based on record review and interviews, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected residents' status based on the criteria outlined in the resident assessment instrument (RAI) for three (#15, #36 and #63) residents out of 40 sample residents. Specifically, the facility failed to: -Ensure the MDS assessments for Resident #15 and Resident #36 accurately documented that the residents had a preadmission assessment screening and resident review (PASRR) Level II qualifying diagnosis; -Ensure the MDS assessment for Resident #15 accurately documented the resident was receiving hospice services; and, -Ensure the MDS assessment for Resident #63 accurately documented the resident was receiving dialysis. Findings include: I. […]

• No harm, potential for more than minimal, patternF880Nov 7, 2024

  Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of four hallways. Specifically, the facility failed to: -Ensure appropriate infection control practices were followed during wound care; and, -Ensure housekeeping staff followed appropriate hand hygiene practices and disinfectant dwell times when cleaning residents' rooms. Findings include: I. Failure to ensure housekeeping staff followed appropriate hand hygiene practices and disinfectant dwell times when cleaning residents' rooms A. […]

• No harm, potential for more than minimal, isolatedF584Nov 7, 2024

  Based on observations and interviews, the facility failed to provide a comfortable and homelike environment in one of four units. Specifically, the facility failed to ensure: -Resident room [ROOM NUMBER], #204, #206, #209, and #212 were in good repair; and, -Baseboards in the common areas on the second floor unit were clean. Findings include: I. Facility policy and procedure The Safe Homelike Environment policy, revised October 2024, was provided by the nursing home administrator (NHA) on 11/8/24 at 10:12 a.m. It revealed in pertinent part, The facility provides a safe, clean, comfortable and homelike environment and allows the resident to use their personal belongings to the extent possible. […]