Medallion Post Acute Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 13, 2025

  Based on record review and interviews, the facility failed to ensure one (#1) of three residents at risk for elopement out of seven sample residents received adequate supervision and were kept free from elopement. Specifically, the facility failed to provide Resident #1 the supervision necessary to prevent elopement. The facility failures created a situation with serious harm and a situation of likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1, diagnosed with metabolic encephalopathy (improper brain function due to underlying medical condition), unspecified psychosis (mental condition caused by loss of contact with reality), dementia and anxiety, eloped from the facility on 2/1/25 at an unknown time. […]

• Immediate jeopardy, isolatedF689Apr 11, 2024

  Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible, affecting three (#1, #2, and #3) out of five residents. Interviews with leadership revealed the facility had transitioned in March 2024 from a non-smoking to a smoking facility. However, a review of the facility's smoking policy (revision date 9/8/22) and the resident smoking safety evaluation in effect in March 2024, revealed they were not reviewed and revised and failed to address oversight and safety interventions for staff to implement as a smoking facility. Further, there were no resident smoking agreements since the transition. […]

• Actual harm, isolatedF684Apr 22, 2025

  Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for one (#2) of three residents out of nine sample residents. Resident #2, who had a history of falling and previous fractures that included a burst fracture of the thoracic vertebra (bone in the upper spine caused by trauma), was admitted to the facility on [DATE]. On 2/11/25 at 6:45 a.m. Resident #2, who ambulated independently with her walker, slipped and fell while walking to the bathroom. After the fall, Resident #2 was heard yelling. A licensed practical nurse (LPN) went to check on the resident and found her lying on her left side, complaining of 8 out of 10 pain, on a 1 to 10 pain scale, to her left shoulder and left hip. […]

• Actual harm, isolatedF684Aug 15, 2024

  Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#4) of two residents reviewed out of 33 sample residents. Resident #4 was admitted on [DATE] for long term care with diagnoses of type 2 diabetes with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failures, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. On 7/12/24 Resident #4 struck her right lower leg on the side of her metal bed frame when she was maneuvering her electric wheelchair near her bed, causing a hematoma (bruise) to her leg. […]

• Actual harm, isolatedF689Feb 16, 2023

  Based on interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#6) of two residents reviewed for falls out of 23 sample residents. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living as documented in her 10/19/22 minimum data set (MDS) assessment. The facility failed to provide staff education and increase resident's supervision to prevent falls when she could not initiate staff assistance by using her call light due to severely impaired cognition. […]