Dawson Health and Rehabilitation

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Housekeeping, the facility failed to ensure that it was maintained in a safe, clean, comfortable environment for one of five bathrooms (Shared with room [ROOM NUMBER]-room [ROOM NUMBER]) on C Hall.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Best Practices for PASSR, the facility failed to submit a Preadmission Screening and Resident Review (PASARR) Level II for one of two residents (R) (R3) reviewed for PASARR. This deficient practice had the potential to affect the appropriate level of care and services provided for R3. Review of policy titled, Best Practices for PASRR, revealed, . There are two areas a person can be a PASSR patient: SMI (Significant Mental Illness or ID/DD Intellectual Disability/Developmental Disability. Review of the Electronic Health Record (EHR) under the Diagnosis tab revealed, that R3 was admitted to the facility on [DATE]. Diagnosis included, but not limited to, an onset psychosis in April 2021. [...]

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Controlled Substance Medication Accountability, the facility failed to ensure the Controlled Drug Record was signed after narcotic administration for three of 33 sampled residents (R) (R47, R4, and R30) during review of three of five medication carts. This deficient practice had the potential to cause incorrect narcotic counts, missed or overdose of narcotic medication for residents.

Inspectors wroteBased on observation, staff interviews, record review and review of the facility's policy titled Hand Hygiene, the facility failed to practice proper infection control protocol by not sanitizing hands between glove change for one of three sampled residents (R) R47 with foley catheter. This deficient practice had the potential to cause infection to R47.

Inspectors wroteBased on documentation review, record review, interviews, and policy review, the facility failed to ensure one of three residents (Resident (R) 23) reviewed for abuse out of a total sample of 19 residents was not physically abused by Certified Nursing Assistant (CNA) 1 while CNA2, CNA3, and CNA4 witnessed the abuse, did not intervene to stop the abuse, and did not report the abuse to the Administrator or Director of Nursing (DON) until 30 minutes after the abuse was witnessed. This resulted in the continued abuse of Resident (R) 23 and put 55 residents in the facility at risk of abuse while CNA1 continued to work for 30 minutes after the abuse was witnessed. The facility's Administrator, the DON, and the Regional Corporate Nurse were informed on 02/03/25 at 4:29 PM that Immediate Jeopardy (IJ) existed at F600L: [...]

Inspectors wroteBased on observation, interview, record review, and review of the manufacturer's manual, the facility failed to ensure residents' bedframes were equipped with the correct mattress dimensions per the manufacturer's manual to reduce the risk of entrapment; and failed to ensure consent for the use of bedrails was obtained prior to the resident's use of bedrails for one of one resident reviewed for bedrails (Resident (R) 155) out of a total sample of 19 residents. R155 was discovered unresponsive in his bed with his upper left extremity in between the bedrail and the mattress. Additionally, review of a facility provided list of all residents' bed frames with the incorrect mattresses and with attached bedrails revealed this failure had the likelihood to affect 47 off 55 residents increasing their risks of entrapment. [...]

Inspectors wroteBased on record review and review of the facility's Administrator's Job Description, the facility failed to be administered in a manner that 1. ensured mattresses were the correct size for 47 out of 55 beds and the safe use of bed rails for resident (Resident (R) 155) and 2. ensured staff did not abuse resident (R23) and additional staff protected the resident from further abuse.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to assess for self-administration of medication for one of one resident (Resident (R) 11) reviewed for self-administration of medication out of a total sample of 19 residents. This had the potential to affect resident medication safety at the facility.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure the accurate code status was documented in the medical record to ensure the resident/family's wishes would be honored for one of 24 residents (Resident (R)23) reviewed for code status in the initial pool. This failure could result in a resident receiving cardiopulmonary resuscitation in the event they coded when their wishes were to not receive cardiopulmonary resuscitation.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to notify the physician for one of two residents (Resident (R) 29) reviewed for change of condition out of 19 sampled residents. R29 was ordered medication as an intervention for pain; however, the resident missed three doses of medication, and the physician was not notified. Additionally, R29 could not fully complete an x-ray due to pain and the nurse failed to notify the physician. This failure prevented the medical provider the opportunity to make changes to the plan of care.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of one resident (Resident) (R) 40) out of a total sample of 19 residents comprehensive social assessments were completed accurately to reflect diagnoses of mental illness and/or intellectual disability (ID). Failure to accurately identify diagnosis of mental illness or ID had the potential to result in the resident not receiving additional specialized services.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate Level I screening prior to admission for one of one resident (Resident (R)40) reviewed for Preadmission Screening and Resident Review (PASRR) out of a total sample of 19 residents. This failure resulted in R40 not receiving a Level II screen for specialized services for mental illness (MI) and/or intellectual disability (ID).

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure a baseline care plan was developed within 48 hours of a resident's admission for one of one resident (Resident (R) 45) reviewed for baseline care plans out of 19 sampled residents.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure the care plan was revised to address pain for one of 19 sampled residents (Resident (R) 29). This deficient practice placed the resident at risk for her pain not to be effectively managed.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to consistently implement a low bed and fall mats for one of four residents (Resident (R) 48) reviewed for accidents out of a total sample of 19 residents. Failing to consistently implement measures when the resident transfers self out of bed and/or chair increased the risk of R48 sustaining an injury.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure pain medication was procured from the pharmacy and administered as ordered by the physician for one of 19 sampled residents (Resident (R) 29). The facility's failure increased the potential for R29 to have untreated pain when three doses of the pain medication were not available from the pharmacy.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Bed Hold During Hospital Stays and Therapeutic Leaves, the facility failed to provide a written bed hold agreement for one of 11 Residents (R1) who was sent to a behavioral facility for medication stabilization. The facility census was 59.