Medford Rehabilitation and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF658Jul 5, 2022

  Based on record review and staff interview, the facility failed to 1. ensure that emergency medical care was provided in accordance with the resident's wishes and accepted standards of professional nursing practice for 1 Resident (#193) out of a total of 36 sampled Residents. Specifically, the facility failed to ensure Nurse #1 followed professional standard of practice by failing to abide by its policy by A) failing to delegate the announcement of the Code Blue (medical emergency) to CNA #1 B) failing to initiate CPR (Cardiopulmonary Resuscitation) immediately in accordance with Resident #193's wishes and C) failing to follow the facility policy regarding use of a back board and transferred the Resident from the bed to the floor before initiating CPR. 2. […]

• Immediate jeopardy, isolatedF678Jul 5, 2022

  Findings include: Review of the facility policy, titled Cardiopulmonary Resuscitation (CPR) and Emergency Response Team, dated ,d+[DATE], indicates the following: Policy: The facility will have an Emergency Response Team (Nurse) available on each shift of every day to immediately respond to all Code Blue (medical emergency) situations prior to the arrival of emergency personnel. Cardiopulmonary Resuscitation (CPR) will be performed on those residents whom are found to be unresponsive, without a Do Not Resuscitate (DNR) order in place and are determined to not be clinically dead. Nursing staff certified CPR providers will perform CPR under those circumstances. […]

• Actual harm, isolatedF655May 25, 2023

  Based on record review and staff interviews, for one Resident (#22) of 28 sampled residents , the facility failed to develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care for him/her, resulting in a fall, requiring nine stitches to his/her right ear. Findings include: Resident #22 was admitted to the facility in January 2023 with diagnosis including dementia, and depression. Review of his/her most recent Minimum Data Set (MDS) dated [DATE] indicated that he/she is severely cognitively impaired and requires extensive 1-person physical assist with ambulation, transfer, bed mobility and toilet use. […]

• Actual harm, isolatedF684May 25, 2023

  Based on observation, record review and interview the facility failed to ensure standards of quality of care for 2 Residents (#18 and #44), out of a total sample of 28 residents. Specifically, 1). for Resident #18 the colonoscopy preparation instructions were not followed, resulting in the procedure not occurring as planned and Resident #18 requiring hospitalization for dehydration and 2). for Resident #44 A. to ensure daily treatment to his/her right second toe was provided in accordance with the physician's orders, resulting in failure to monitor the wound for changes, pain, signs and symptoms of infection. Further, the treatment that was provided included a dressing which was not indicated by the physician's order potentially resulting in keeping the area moist and not dry. B. […]

• Actual harm, isolatedF689May 25, 2023

  Based on observation, record review and interview the facility failed ensure residents identified as being at risk for falls received adequate supervision and revision of care plan interventions as needed to prevent falls, resulting in falls with injury for 2 Residents (#125 and #88) out of a total of 28 sampled Residents. Findings include: Review of the facility's Fall Prevention policy, revised 11/21/21 indicated: Policy: A fall prevention plan will be initiated on all Residents who are at risk for falling. Each Resident will be assessed for risk factors and predisposition. Process: 2. A fall risk assessment will be completed and Residents scoring at risk for falls will have the following interventions. 3. […]