Melbourne Terrace Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Melbourne Terrace Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 19, 2024

  Based on interview, and record review, the facility failed to protect the resident's right to be free from neglect by not ensuring staff implemented measures to mitigate the risk to prevent elopement for 1 of 5 residents reviewed for elopement, of a total sample of 5 residents, (#1). These failures contributed to the elopement of resident #1 and placed her at risk for serious injury, impairment, and/or death. While resident #1 was out of the facility unsupervised, there was likelihood she could have fallen, been accosted by unknown persons, become lost or been hit by a vehicle. On 8/04/24 at approximately 7:45 PM, the facility failed to prevent resident #1, a newly admitted female with a documented risk of elopement from exiting the facility unsupervised. […]

• Immediate jeopardy, isolatedF689Sep 19, 2024

  Based on interview, and record review, the facility failed to provide adequate supervision and a secure environment to prevent elopement of 1 of 5 residents reviewed for elopement, of a total sample of 5 residents, (resident #1). On 8/02/24 resident #1 a cognitively impaired [AGE] year-old female was admitted to the facility from the hospital. While at the hospital she was determined to be at risk of falls, wandering, and elopement. On 8/04/24, at approximately 7:45 PM, resident #1, exited the facility's front entrance when the receptionist, distracted by other departing visitors unlocked the front door and allowed her to leave from the facility unsupervised. The facility was unaware of her whereabouts overnight, for approximately 13 hours. […]

• No harm, potential for more than minimal, widespreadF812Dec 5, 2024

  Based on observation, interview, and record review, the facility failed to ensure food items were stored in a safe manner by failing to accurately label and date food items, keep food items properly contained, and used by the discard date. This failure had the potential to negatively affect all 165 of the 165 residents who consumed food by mouth at the facility. Findings: 1. On 12/02/4 at 10:15 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM) in the walk-in refrigerator, a previously opened plastic container of chicken base and another of beef base were noted to not have dates as to when they had been opened. The CDM verified this and removed these from the refrigerator to discard. […]

• No harm, potential for more than minimal, patternF867Dec 5, 2024

  Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's current QAPI Plan revealed the facility would use a performance improvement focus to increase quality throughout the facility. This process included identifying areas of weakness to create potential solutions. The plan indicated these solutions would be identified on the Performance Improvement Plan (PIP) which would be monitored by associates using specific audit tools to determine if changes were successful. […]

• No harm, potential for more than minimal, patternF812Apr 13, 2023

  Based on observation, interview, and record review, the facility failed to ensure potentially hazardous foods were at a hot holding temperature of 135 degrees Fahrenheit, or above, to prevent foodborne illness. Findings: On 4/11/23 at 11:55 AM, observation of 1 of 2 facility kitchenettes/dining areas called The Tavern was conducted. Dietary Aide A used a thermometer to check the hot food temperature on the steam table but failed to remove the thermometer probe cover. The temperature of the shredded barbeque pork read 99 degrees Fahrenheit. Dietary Aide A then removed the probe cover and calibrated the thermometer in ice water. […]