Treyburn Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Jun 19, 2024

  Based on record review and interviews with staff, Responsible Party (RP) and Physicians the facility failed to immediately notify the responsible party when Resident # 6's intravenous fluids (IV) infiltrated (IV fluids going into the surrounding tissue instead of the vein), and the fluids were placed on hold. At the time of infiltration, the resident had already been identified to have new swallowing problems, nausea, and no food intake for multiple consecutive meals. Resident # 6's family reported she would have requested the resident be sent to the hospital if she had known about any delay with the IV fluids. After the IV infiltration, the resident was transferred hours later to the hospital and admitted to the Intensive Care Unit for a principal diagnosis of sepsis. […]

• Immediate jeopardy, isolatedF684Jun 19, 2024

  Based on record review and interviews with staff, resident, Responsible Party (RP, ) Nurse Practitioner, Physician Assistants, and Physicians the facility failed to effectively communicate amongst their staff and with the medical providers and family and to ensure assessment and treatment occurred for a resident who was showing signs of a change in condition and whose family had initially requested the resident be transferred to the hospital but agreed with facility treatment based on the understanding the resident would receive appropriate evaluation and treatment at the nursing home. […]

• Actual harm, isolatedF689Jun 19, 2024

  Based on record review and staff interviews, the facility failed to investigate the root cause of the repeated falls and provide supervision to prevent more falls from occurring. One of these falls required hospital intervention with sutures for lacerations to the nose and forehead and another fall the same day required hospital intervention with additional sutures to the back of the head. This resident did not return to the facility after the last fall with injury. This deficient practice was identified for 1 of 3 residents reviewed for accidents (Resident #8). […]

• No harm, potential for more than minimal, patternF812Feb 29, 2024

  Based on observations, record review and interviews the facility failed to discard expired food from the walk-in refrigerator, label and date thickened liquids in reach-in refrigerator and maintain the kitchen equipment and bin holding scoops and ladles clean. The facility failed to label, and date opened dietary supplements and thickened liquids, and discard expired food from 2 of 2 nourishment refrigerator (Nourishment refrigerator in Kitchenette #2 and Kitchenette #1). These practices had the potential to affect food served to the residents. Finding included: 1. An observation of the walk-in refrigerator on [DATE] at 9:17 AM revealed an aluminum pan containing multiple individual cups of yogurt and nutritional supplements on ice. […]

• No harm, potential for more than minimal, patternF867Feb 29, 2024

  Based on observations, record reviews, resident and staff interviews, the facility's Quality's Assessment and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that were put in place following the annual recertification and complaint survey conducted on [DATE]. This was for recited deficiencies in the areas of Food Procurement/Prepare/serve-Sanitary (F812) and Care Plan Timing and Revision(F657). These deficiencies were recited during an annual recertification and complaint survey conducted on [DATE]. […]