Ostrander Care and Rehab

In the surveyor’s words

From the most serious findings on record at Ostrander Care and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 8, 2021

  Based on observation, interview, and document review the facility failed to monitor and evaluate signs/symptoms of [CONDITION(S)] (skin infection) and fluid volume status and [CONDITION(S)] (swelling) for 1 or 2 residents (R4). The facility's failure to monitor and evaluate worsening skin conditions for timely treatment resulted in harm when R4 was hospitalized for [CONDITION(S)]. Findings include: R4's facility face sheet, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R4 did not have a cognitive impairment and did not have behaviors. The MDS indicated R4 was independent with activities of daily living with exception of personal hygiene which R4 required physical assistance from one staff. […]

• Actual harm, isolatedF689Apr 8, 2021

  Based on interview and record review the facility failed to conduct a thorough analysis of resident's falls in a timely manner, review of appropriate patient-centered interventions, evaluate the effectiveness of current interventions to prevent and/or reduce the likelihood of future falls and complete incident reports when a resident is found on the floor for 2 of 4 residents (R13 and R9) reviewed for accidents. The facilities failure resulted in harm when R13 had 8 falls with the 12/12/21 having resulted in a hospitalization with diagnosis of fractures and continued to have falls after readmission to the facility. […]

• Actual harm, isolatedF690Apr 8, 2021

  Based on interviews and document review, the facility failed to intervene timely for 1 of 1 residents (R)3 with a known history or urinary tract infections, stones and [CONDITION(S)] [critical infection if not treated results in death] who required immediate medical interventions for lack of urine output. This resulted in harm when R3 was hospitalized with [CONDITION(S)] and kidney stones. Findings include: R3 admission record indicated readmitted [DATE]. R3 admitted to hospice on 3/25/21. R3 discharge date of [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Nov 8, 2023

  Based on observation, interview and document review, the facility failed to ensure dishmachine chemical sanitization solution was appropriately monitored to ensure dishes were properly sanitized. This had the potential to effect all 18 residents who resided in the facility. Findings include: During an observation and interview on 11/06/23 at 12:49 p.m., with dietary supervisor (DS)-C, observed the dishmachine in use. DS-C stated the dishmachine used low temperature heat and chemical to sanitize the dishes. While observing the dishmachine in use, dietary aide (DA)-A was asked to test the sanitizing solution. DA-A obtained a white Ecolab brand test strip from a container with expiration date of 5/1/24, and placed a strip in the water at the bottom of the dishmachine. […]

• No harm, potential for more than minimal, widespreadF851Nov 8, 2023

  Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 3, 2023), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: During an interview on 11/07/23 at 2:50 p.m., facility PBJ Staffing Data Report for quarter 3, 2023 (April 1 - June 30), was reviewed with the administrator. The specific metric titled: failed to have licensed nursing coverage 24 hours/day had been triggered for the following infraction dates: 5/20/23, 5/21/23, 5/30/23, 6/17/23, 6/26/23, 6/27/23, 6/30/23. […]