Tower Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Jul 6, 2023

  Based on record review, staff interview, Physician Assistant interview, Physician interview, and hospice staff interview the facility failed to notify the physician of bruising to Resident #2's right hip and thigh that was identified on 5/21/23 by Nursing Assistant (NA) #1 and Nurse #3 two days following a fall (5/19/23). The bruising continued through 5/31/23 and was accompanied by swelling. On 5/31/23 the resident also showed signs of pain. On 5/31/23 the resident was admitted to the hospital with a comminuted and angulated hip fracture (a comminuted fracture is when the bone is broken into more than two pieces, and an angulated fracture is where the ends of the bone fragments are at an angle to each other) and significant bruising from the right hip to thigh hip fracture. […]

• Immediate jeopardy, isolatedF684Jul 6, 2023

  Based on record review, staff interview, Physician Assistant interview, Physician interview, and hospice staff interviews the facility failed to communicate effectively to ensure comprehensive assessment and care were provided to address bruising to Resident #2's right hip and thigh that was first identified on 5/21/23 by Nursing Assistant (NA) #1 and Nurse #3 two days following a fall (5/19/23). The facility continued to transfer the resident via stand pivot method with weight being placed on the right leg and on 5/30/23 NA #3 noted the resident's right leg was in an awkward position and he straightened it. […]

• Immediate jeopardy, isolatedF689Jul 6, 2023

  Based on record review, review of manufacturer's instructions, and staff interviews, the facility failed to ensure securement was according to manufacturer's recommendations to provide a safe van transport. Resident #50 slid out of a reclined high back wheelchair into a seated position on the floor of the van with his legs extended in front of him and the seatbelt was above his head. Resident #50 alerted the transportation driver he had fallen. The transportation driver stopped the van in the center turning lane of a well-traveled road in the afternoon with the hazard lights on and lifted the Resident back into the high back wheelchair in a bear hug motion. The transportation driver proceeded to take Resident #50 to his appointment, failing to report the incident to the facility. […]

• Immediate jeopardy, isolatedF600Oct 15, 2022

  Based on record review, staff interviews and physician interview the facility failed to protect a resident's right to be free from abuse. Staff provided care on a cognitively impaired resident who was resisting and flailing her arms and legs. The resident's arm was held down while care was provided, and staff continued to provide care even when they knew it was a struggle. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was for 1 of 1 resident reviewed for abuse (Resident #222). Immediate Jeopardy began on 3/25/22 when NA #1 (Nursing Assistant) and NA #2 provided care to Resident #222 when the resident was resistant, and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF610Oct 15, 2022

  Based on staff interview and record review the facility failed to protect residents when NA #1 and NA #2 were not removed from resident care assignments after an allegation of abuse with Resident #222. NA #1 and NA #2 continued to provide resident care. This had the high likelihood to put other residents at high risk for abuse and harm. The facility also failed to conduct a thorough investigation. Immediate jeopardy began on 3/25/22 when the facility allowed NA #1 and NA #2 to continue working after Resident #222 stated, That bitch broke my leg and She was yanking on it. The immediate jeopardy was removed on 10/15/22 when the facility implemented a credible allegation of jeopardy removal. […]