Fresh River Healthcare

In the surveyor’s words

From the most serious findings on record at Fresh River Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF600May 25, 2022

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident # 2) reviewed for abuse, the facility failed to ensure a resident was free from sexual mistreatment. The findings include: Resident #1 was admitted on [DATE] with diagnoses that included cerebral infarction (CVA), osteoporosis and anxiety. An Interdisciplinary Rehabilitation Screen dated 2/4/22 noted Resident #1 was independent with bed mobility, transfers, Independent with ambulation using a rolling walker. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, was independent with locomotion on the unit using a wheelchair and required extensive one person assist for toileting. […]

• Actual harm, isolatedF689Apr 27, 2021

  Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident # 10) reviewed for accidents, the facility failed to implement enhanced supervision for a resident exhibiting behaviors of restlessness resulting in an injury that required sutures to close the wound. The findings include: Resident #10 was admitted on [DATE] with diagnoses that included [CONDITION(S)], [CONDITION(S)] and essential hypertension. The quarterly (MDS) assessment dated [DATE] identified Resident #10 with impaired cognition was independent with bed mobility, transfer to wheelchair from bed and toilet and self-mobile with wheelchair, assist of one with ambulation, and indicated the resident did not exhibit wandering behavior. […]

• No harm, potential for more than minimal, patternF550Aug 18, 2023

  Based on clinical record reviews, observations, facility documentation review, facility policy review, and interviews for nine sampled residents ( #19, #21, #26, #29, #41, #49, #74, #77, and #110) who resided on a secured unit, the facility failed to ensure Resident Rights were maintained by not permitting residents to leave the secured unit for the first seventy-two hours following admission and after the initial seventy-two hours the residents are not permitted to leave the unit without being escorted by a staff member for up to two weeks, and when residents' were permitted to leave independently, they were required to wear a lanyard that identified that they resided on the secured unit. […]

• No harm, potential for more than minimal, patternF553Aug 18, 2023

  Based on review of the clinical record, facility documentation review, facility policy review, and interviews for two of three sampled residents (Resident #29 and #49) reviewed for Resident Rights, the facility failed to allow the resident the right to participate in the development and implementation of his or her person-centered plan of care. The findings include: 1. Resident #29's diagnosis included schizophrenia bipolar type, history of alcohol abuse, legally blind, hypertension, and chronic diastolic pulmonary disease. […]

• No harm, potential for more than minimal, patternF657Aug 18, 2023

  Based on clinical record review, observations, review of facility documentation, review of facility policy and interviews for five of five sampled residents (Resident #13, #29, #41. #49 & #74) reviewed for care planning, the facility failed to ensure that the care plan conferences involved the complete interdisciplinary team and failed to ensure that residents were included in the care plan development. The findings include: 1. Resident #13's diagnoses included Type 2 diabetes, schizoaffective disorder, and vascular dementia. […]