Falls Run Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Falls Run Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Mar 16, 2023

  Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for three of 37 residents in the survey sample, Residents #32, #31, and #6. The findings include: 1. For Resident #32 (R32), the facility staff failed to implement the care plan to attempt non-pharmacological interventions as part of the resident's pain management program. A review of R32's physician orders revealed the following order dated 1//17/23: Oxycodone-Acetaminophen (opioid pain medication) 5-325 mg (milligrams) .Give 1 tablet by mouth every 8 hours as needed for moderate or severe pain. […]

• No harm, potential for more than minimal, patternF697Mar 16, 2023

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain management program for two of 37 residents in the survey sample, Residents #32 and #6. The findings include: 1. For Resident #32 (R32), the facility staff failed to offer non-pharmacological interventions and assess for the location of a resident's pain prior to administering an as needed pain medication on multiple occasions in March 2023. A review of R32's physician orders revealed the following order dated 1/17/23: Oxycodone-Acetaminophen (opioid pain medication) 5-325 mg (milligrams) .Give 1 tablet by mouth every 8 hours as needed for moderate or severe pain. […]

• No harm, potential for more than minimal, patternF757Mar 16, 2023

  Based on staff interview and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 37 residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff administered the as needed pain medication, tramadol, outside of the physician's order for pain rated between six to ten on a scale of one to ten (one being least and ten being most) on multiple dates in January 2023 and February 2023. The staff administered tramadol for a pain rating less than six. A review of R6's clinical record revealed a physician's order dated 11/23/20 for tramadol 50 mg (milligrams)- one tablet by mouth every eight hours as needed for pain rated six to ten. […]

• No harm, potential for more than minimal, patternF623Aug 26, 2021

  Based on staff interview, facility document review, and clinical record review, the facility staff to provide evidence of written notification to the resident and or RP (responsible party) for hospital discharges for four of 28 residents in the survey sample, Residents #67, #14, #35, and #44. The findings include: 1. The facility staff failed to evidence written notification to the RP [responsible party] of Resident #67's discharge to the hospital on 8/19/21. Resident #67 was admitted to the facility on [DATE], and most recently readmitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF812Aug 26, 2021

  Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to ensure food storage in a safe manner, and failed to clean the kitchen stove. The walk-in refrigerator contained expired milk cartons and pudding. The stove top contained areas of built-up grease that was burned on to the grates, elements, and stove top surface. The stove top also contained ashy material that scraped up easily with a gloved finger. The findings include: On [DATE] at 10:50 a.m., observation was made of the facility kitchen. The walk-in refrigerator contained approximately 1 ,d+[DATE] quarts of a dark brown, thick substance labeled nutritional pudding. The label had an expiration date of [DATE]. […]