Phelps Health

In the surveyor’s words

From the most serious findings on record at Phelps Health, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF700Jan 19, 2023

  Based on observation, interview and record review, facility staff failed to complete entrapment assessments for the use of bed rails for 6 residents (Resident #2, #6, #209, #211, #212, and #214). The facility census was 10. 1. Review of the facility policies provided showed the facility did not have a policy for bedrails/mobility assist devices. Review of the facility's VersaCare Bed Service Manual, revision 5, undated, showed the manual did not address risk of resident entrapment. 2. […]

• No harm, potential for more than minimal, isolatedF636Dec 28, 2023

  Based on interview and record review, the facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for two of three sampled residents (Residents #2 and #162). The facility census was 10. 1. Review of the facility's MDS Automation policy, revised April 2021, showed: -The MDS will be completed on a timely basis as mandated by Centers for Medicare Services (CMS); -Discharge tracking forms are completed on every resident within five days of dismissal; -The MDS assessments as required are sent to the state through electronic submission every 7-10 days. […]