Kutz Rehabilitation and Nursing

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that a performance review was completed at least every twelve months for five (E17, E18, E19, E20 and E21) out of five sampled employees.

Inspectors wroteBased on interview, record review, and review of other facility documents, it was determined for one (R10) out of three residents reviewed for abuse, the facility failed to ensure that R10 was free from verbal abuse from a staff member.

Inspectors wroteBased on interview, record review, and review of other facility documents, it was determined for one (R10) out of three residents reviewed for abuse, the facility failed to ensure that the allegation of verbal abuse from a staff member was reported to the State Survey Agency within the required time.

Inspectors wroteBased on interview and record reviews, it was determined that for two (R16 and R79) out of six residents reviewed for ADLs (Activities of Daily Living), the facility failed to ensure each dependent resident received the necessary services to maintain grooming and personal hygiene. For R16, the facility failed to provide incontinence care during the evening shift when her clothes and linens were found saturated with urine. For R79, the facility failed to ensure that R79's morning care was done when he was found wearing his pajamas in the afternoon.

Inspectors wroteBased on interview and record review, it was determined for one (R81) out of three residents reviewed for accidents, the facility failed to ensure that R81 received adequate supervision and assistance to prevent accidents to the extent possible.

Inspectors wrote3. A review of R11's clinical record revealed: 3/24/21 - R11 was admitted to the facility. 11/16/24 - R11 was admitted to hospice care. 3/12/25 - A review of the medications on the 2/26/25 hospice plan of care document in the electronic medical record (EMR) compared to the medications that the facility had profiled for R11 in the facility EMR revealed the following discrepancies: -Ativan 0.5 mg by mouth every four hours as needed for agitation that was ordered by hospice on 11/16/24 was on the hospice medication list but not on the current facility medication list. -Miralax 17 grams, 1 scoop daily by mouth for constipation, was ordered by the facility on 11/1/24 was on the facility medication profile, but not on the hospice list of medications. [...]

Inspectors wroteBased on interview and review of clinical records and other documentation as indicated, it was determined that for four (R63 and R23) out of eight residents reviewed for falls, the facility failed to ensure that each residents' plan of care was followed to prevent accidents. For R63, the facility improperly transferred the resident using one staff person stand and pivot when R63 required two staff persons and hoyer lift. As a result, R63 was harmed when the resident sustained a lower leg laceration requiring sutures in the emergency room. For R23, a dependent resident for bed mobility, rolled off the bed on to the floor during incontinence care. R23 was sent to the emergency room after the fall.

Inspectors wrote2. A review of R19's clinical record revealed: 3/3/22 - R19 was admitted to the facility with diagnoses including a stroke which affected his right dominant side, cerebral palsy, and muscle weakness. 1/5/25 - R19's most recent quarterly MDS documented a BIMS' score of 10, which indicated a mild cognitive impairment, and R19 required substantial assistance with toileting. 1/15/25 - A facility's reported incident submitted to the Division documented, that R19 reported to E21 (LSW) at approximately 2:30 PM he asked E22 (CNA) to use the toilet. E22 entered his room and asked, What do you want? R19 stated that he needed to use the bathroom, and E22 replied, Its's too late, you should have asked to go to the bathroom at 2:00 PM. R19 described E22 as yelling at him and being Really mad. [...]

Inspectors wroteBased on record review and interview, it was determined that for four (R5, R13, R19 and R65) out of fourteen residents reviewed for abuse, the facility failed to report the allegations of neglect/abuse and injury of unknown source to the State Agency within the required timeframe.

Inspectors wroteBased on record review, observation and interview, it was determined that for four (R5, R23, R27, R47) out of four residents reviewed for bedrails, the facility failed to assess the residents prior to installing the bedrails/enablers and failed to obtain consent from the resident/POA/resident representative.

Inspectors wrote3. Cross refer to F760, example 4 On 10/28/24 at 2:10 PM, the facility reported the following medication error incident to the State Agency: On Monday, October 7, 2024 nursing supervisor informed DON that medications had been found on a medication cart and left un-administered. Supervisor investigated and found that all medications had been documented as 'Administered'. Schedule review showed that LPN [name of E46] had been assigned to the residents whose medications were left un-administered . The incident occurred on 10/3/24 day shift and involved the following four residents: R4, R47, R52 and R84. 11/4/24 - The facility's 5-day follow-up investigation submitted to the State Agency reported: . the facility is able to SUBSTANTIATE . [...]

Inspectors wroteBased on record review and interview, it was determined that for four (R7, R17, R41 and R68) out of fourteen residents reviewed for medications, the facility failed to ensure the residents were free from significant medication errors. For R68, the facility failed to prevent R68 from receiving three doses of Zosyn in six hours on 2/11/25. For R7, the facility failed to obtain R7's cortef (a critical med) from 10/28/24 to 11/2/24. For R17, the facility failed to have available R17's sevelamer medication causing R17 to miss twenty-seven out of seventy-two opportunities for this medication administration from 3/10/25 to 3/25/25. For R41, the facility failed to have the resident's Dovato and Formoterol medications available.

Inspectors wroteBased on interview, record review and identified deficiencies during the survey, it was determined that the facility's QAPI program failed to effectively address ongoing issues that impact quality of care with respect to staff to resident abuse, repeated medication errors by nursing staff and the continued lack of availability of medications from the pharmacy for multiple residents.

Inspectors wroteBased on record review and interview, it was determined that for one (R45) out of ten residents reviewed for antibiotic use, the facility failed to ensure that an antibiotic stewardship program was implemented that consistently monitored prescription antibiotic usage.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to implement and maintain an effective training program for new LPN staff regarding intravenous medication administration prior to being assigned to independently provide this service to R68 on 2/11/25.

Inspectors wroteBased on observation, record review and interview, it was determined that for one (R26) out of thirty-five sampled residents, the facility failed to treat R26 with dignity.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R23) out of thirty-five residents sampled, the facility failed to provide a special need for a larger bed. R23 rolled out of the bed on to the floor during incontinence care and was transported to the emergency room for evaluation and treatment.

Inspectors wroteBased on interview and review of clinical record and other documentation as indicated, it was determined that for one (R7) out of thirty-five sampled residents, the facility failed to consult the provider of the significant change in R7's physical status with her heart rate (HR) running in the 40's.

Inspectors wroteBased on review of the facility's Resident Abuse Policies and Procedures, last revised 12/2023, it was determined that the facility failed to develop a written policy and procedure that clearly addressed sections under Identification and Reporting.

Inspectors wroteBased on record review and interview, it was determined that for one (R26) out of fourteen residents reviewed for abuse, the facility failed to report their investigation results to the State Agency within 5 working days of the incident.

Inspectors wroteBased on observation, interview and record review, it was determined that for two (R17 and R23) out of thirty-five residents sampled, the facility failed to develop and implement a comprehensive person-centered care plan for R17 that included specific directions for taking vital signs on a resident with a dialysis fistula. For R23, the facility failed to include bed enablers as an intervention on the care plan.

Inspectors wroteBased on record review and interview, it was determined that for one (R11) out of four residents sampled for range of motion, the facility failed to provide R11 with a right-hand palm guard that was ordered on 5/2/24.

Inspectors wroteBased on observation and interview, it was determined that for one (R17) resident out of three residents reviewed for tube feedings, the facility failed to consistently and correctly label R17's tube feeding solution.

Inspectors wroteBased on observation, record review and interview, it was determined that for one (R72) out of one resident reviewed for respiratory, the facility failed to ensure R72's O2 tubing was replaced weekly as per professional standards of care.

Inspectors wroteBased on record review and interview, it was determined that for one (R72) out of thirty-five residents reviewed for physician services, the facility failed to ensure that the physician reviewed the residents' total program of care.

Inspectors wroteBased on record review and interview, it was determined that for three (R14, R17 and R23) out of three residents reviewed for pharmacy services, the facility failed to provide pharmaceutical services to meet the needs of each resident.

Inspectors wroteBased on interview and review of a clinical record and the Medication Regimen Review (MRR) policy and procedure, it was determined that the facility failed to ensure the MRR policy had specified response time frames included for the different steps. In addition, for one (R48) out of eight residents reviewed for pharmacy, the facility failed to ensure that R48's pharmacy recommendation was acted upon before a second recommendation was made.

Inspectors wroteBased on record review and interview, it was determined that for one (R48) out of five residents reviewed for unnecessary medications, the facility failed to identify and clarify a drug allergy with a medication ordered by a consultant physician before administering it to R48.

Inspectors wroteBased on observation and interview, it was determined that for one out of three medication carts observed, the facility failed to adhere to proper labeling and storage practices for insulin pens as per regulatory standards and best practices. Findings Include: [DATE] 12:00 PM - Upon observation of insulin administration for R61, the surveyor observed that the insulin aspart pen was open and used, but there was no indication of an open date on the medication. The absence of an open date on the insulin pen created a risk of using expired medication, which could compromise resident safety and treatment efficacy. [DATE] 12:01 PM - Interview with E8 (LPN) confirmed that no open date was labeled on the pen.

Inspectors wroteBased on record review and interview, it was determined that for two (R27 and R42) out of eight residents reviewed for falls, the facility failed to ensure that each resident had a complete and accurate medical record.

Inspectors wroteBased on record review and interview, it was determined that one (R78) out of ten residents reviewed for Infection Control, the facility failed to order and maintain Enhanced Barrier Precautions (EBP) for R78 when he had an indwelling catheter from [DATE] to [DATE].

Inspectors wroteBased on observation, interview, and record review, it was determined that for one (R17) out of thirty-five (35) sampled residents reviewed, the facility failed to ensure that R17 had functioning call bell systems to request staff assistance.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to prevent a fall for one of seven residents reviewed for falls (Resident (R) 30). This failure resulted in harm to R30 when the nursing assistant failed to ensure R30 was safe while dressing her in her room; R30 fell and suffered a concussion and an abrasion to her forehead and was hospitalized for eight days.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one out of two residents (Resident (R) 8) reviewed for bowel and bladder was assessed following a decline in continence. In addition, the facility failed to ensure R8 had services and care implemented to maintain as much continence as possible. R8 declined from being continent/mostly continent of urine to becoming incontinent of urine and wearing incontinent briefs following a decline in her ability to use the walker and go to the toilet.

Inspectors wroteBased on interviews and review of the Resident Council Meeting Minutes, the facility failed to provide feedback and/or resolutions to resident complaints and/or grievances discussed in the monthly resident council meetings in 12 of 13 resident council meetings.

Inspectors wroteBased on record review, interview, and policy review, the facility failed facility failed to thoroughly investigate and document abuse investigations for three of 25 sampled residents (Resident (R) 8, R27, and R48). 1. Review of the undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R8 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, weakness, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/23, located in the EMR MDS tab, revealed R8's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R8 required substantial/maximal assistance with toileting hygiene, and she was always incontinent of bowel and bladder. [...]

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure the kitchen was maintained in a sanitary condition for 79 out of 82 total residents (three residents received nutrition via feeding tubes). Specifically, foods and utensils were not stored appropriately and kitchen surfaces were not clean.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one of 25 sampled residents' (Resident (R)11) physicians was notified of a change in condition. R11 was documented as refusing to wear her left resting hand splint most of the time over the past two weeks. R11's Physician had not been notified creating the potential that the need for treatment to be modified would not occur.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to make prompt efforts to resolve grievances and report the findings in writing to the resident/family for one of 25 sampled residents (Resident (R) 8).

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from neglect when eight residents (Resident (R) 65, R12, R26, R30, R38, R68, R70, and R233) were not provided care on the 100 B Unit out of 73 residents that resided in the facility on 02/01/23. Certified Nursing Assistant (CNA) 1 left the facility without informing staff he was refusing to care for the residents. During this time, R65 sustained a fall in her room and was found by restorative certified nursing assistants.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to implement policies and procedures for ensuring the reporting of potential neglect and abuse within two hours for two allegations of neglect/abuse involving nine of twenty-five sampled and four supplemental residents (Resident (R) 8, R65, R12, R26, R30, R38, R68, R70, and R233). The facility failed to report to the State Survey Agency (SSA) an allegation made by R8 that her certified nursing assistant (CNA) unplugged her call light and failed to report when a CNA did not provide care for eight assigned residents for on hour on 02/01/23.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of four residents (Resident (R) 35 and R51) reviewed for hospitalization were provided with a written transfer notice upon emergent transfer to the hospital.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure two out of four residents (Resident (R) 35 and R51) reviewed for hospitalization were provided with bed hold notices within 24 hours of emergent transfer to the hospital.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure the care plan was updated for one out of 25 sampled residents (Resident (R) 8) following a change in the resident's ability to ambulate, transfer, use the toilet, and remain continent of urine. This created the potential R8 would not receive appropriate care and services to reach her highest practicable level.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to notify the wound nurse practitioner when an alteration in skin was identified so wound treatment could be ordered and followed by staff for one of three residents (Resident (R) 7) reviewed for pressure ulcers. This failure had the potential to cause infection, and worsening of a pressure ulcer when treatment was not provided to R7's unstageable sacral wound for six days.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one of one resident (Resident (R)11) reviewed for range of motion (ROM) received services to maintain range of motion ROM. R11's hand splint was not applied in accordance with Physician's orders.