Neodesha Care and Rehab

Inspectors wroteBased on observation, interview and record review, the facility failed to provide eight consecutive hours of registered nurse staff on a daily basis for the residents of the facility.

Inspectors wroteThe facility reported a census of 38 residents and one main kitchen. Based on observation, interviews and record review the facility failed to store, prepare and serve food in a sanitary manner.

Inspectors wroteThe facility reported a census of 38 residents. Based on observation, interviews, and record review, the facility failed to ensure staff served palatable meals to the residents when the staff served dry, burnt ham to the residents on 04/12/26 for the lunch meal.

Inspectors wroteBased on interviews, observation and record review, the facility failed to ensure adequate hand hygiene during medication administration for Resident (R) 28, a tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube) for R5, and for hands-on care for R30 and R3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician for Resident (R) 30 was informed when the resident had refused several medications which included an antibiotic for a urinary tract infection (UTI - an infection in any part of the urinary system).

Inspectors wroteThe facility identified a census of 38 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to provide dependent Resident (R) 30 with activities of daily living (ADL) services, including shaving of facial hair.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor and respond to Resident (R) 30's lack of bowel movements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate care and services for Resident (R) 22's peripherally inserted central catheter (PICC - a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) when staff failed to perform the PICC dressing change every seven days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately post daily nurse staffing information for Registered Nurses, Licensed Practical Nurses, Certified Nurse Aides, the resident census, and the total number of scheduled hours and actual hours worked by each category for each shift, as required.

Inspectors wroteThe facility reported a census of 38 residents. Based on observations, interview, and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly.

Inspectors wroteBased on observation, interview and record review, the facility failed to electronically submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) related to weekend staffing.

Inspectors wroteThe facility reported a census of 41 residents; the sample included four residents. Based on observation, interview, and record review, the facility failed to ensure residents remained free from significant medication errors when staff administered anti-anxiety medications (medications used to treat anxiety, which calm and relax individuals experiencing anxiety) incorrectly for Resident (R)1.

Inspectors wroteThe facility reported a census of 29 residents. Based on record review and interview, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS i.e., Payroll Base Journal (PBJ), related to licensed nursing licensed and certified nursing staffing information when the facility failed to accurately report weekend staffing for the third quarter 2023 April through June.

Inspectors wroteThe facility reported a census of 29 residents. Based on observation, interview and record review, the facility failed ensure a plan to monitor the effectiveness of recommended measures put in place following identification of positive Legionella (a pneumonia [lung infection] bacteria found in water) detected in the facility water system in March 2024 and April 2024. In addition, the facility failed to ensure five combs and one hair brush were stored in a sanitary manner in the beauty shop.

Inspectors wroteThe facility reported a census of 29 residents with 13 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure appropriate monitoring of psychotropic medications (a medication which affects behavior, mood, thoughts, or perception) for one Resident (R)5, regarding the use of anti-depressant medications (medications used to treat depression).

Inspectors wroteThe facility reported a census of 36 residents, with 12 sampled, including four residents sampled for pressure ulcers. Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to prevent pressure ulcers (PU, localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failure to perform skin assessments under a medical immobilization device for Resident (R) 3, allowing an unstageable (full thickness tissue loss in which actual. depth of the ulcer is completely obscured) PU to develop.

Inspectors wroteThe facility census totaled 36 residents, with 12 sampled, including five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure adequate follow-up of the consultant pharmacist recommendations regarding Depakote (anti-convulsant medication, sometimes used for the manic episodes associated with bipolar) for Resident (R) 10, regarding decreasing the dose of this medication. This failure placed the resident at risk for adverse effects related to medication use. Findings Included: - R10's 11/29/22 Electronic Health Record (EHR), documented diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder). [...]

Inspectors wroteThe facility census totaled 36 residents, with 12 sampled, including five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure reduction in Depakote (anti-convulsant medication, sometimes used for the manic episodes associated with bipolar) for Resident (R) 10, by not decreasing the medication as ordered. This failure placed the resident at risk for adverse effects related to medication use. Findings Included: - R10's 11/29/22 Electronic Health Record (EHR), documented diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder). [...]