New Dawn Rehabilitation and Healthcare Center

Inspectors wroteBased on interview and closed record review the facility failed to correctly transcribe a resident's pain medication orders resulting in missed doses and pain. This affected one (Resident #81) of three residents reviewed for pain. The facility census was 72.

Inspectors wroteBased on medical record review, review of hospital records, review of the facility's investigation, facility policy review and interviews, the facility failed to provide necessary and timely treatment for Resident #10 following a reported injury by the resident. This affected one resident (#10) of three residents reviewed for accident hazards. Actual harm occurred on 04/18/26, when Resident #10 reported to staff that someone dropped her last night while getting changed and she had left knee pain. The resident's left knee was noted to be swollen, and she could only slightly lift her knee. Licensed Practical Nurse (LPN) #15 administered as needed Tylenol for pain. LPN #15 failed to notify the resident's medical provider of the reported fall and change in condition of Resident #10 resulting in delaying necessary treatment including x-rays and orthopedic consult. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents receiving psychotropic medications were provided education on the risks/ benefits of those psychotropic medications for them or their resident representative to be able to give an informed consent for the use of those medications. This affected five residents (#3, #8, #9, #53, and #76) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and considering the number, acuity, and diagnoses of the facility's resident population. This affected 68 of 68 residents residing in the facility. The facility census was 68.

Inspectors wroteReview of review of the facility infection control log, interview, and policy review the facility failed to have a comprehensive infection control program and failed to ensure staff were knowledgeable on the laundry process for infectious linens. This affected all 68 residents residing in the facility. The facility census was 68.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to maintain an effective antibiotic stewardship program. This affected all 68 residents residing in the facility. The facility census was 68.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe environment when facility dryers were not maintained. This had the potential to affect all residents residing in the facility. The census was 68.

Inspectors wroteBased on paper and electronic medical record review, review of emergency binder, interview, and policy review the facility failed to ensure resident advance directives were accurate in all records. This affected four residents (#2, #6, #10, #76) of four residents reviewed for advance directives.

Inspectors wroteBased on medical record review, observation, review of pictures, review of concern log, and interview the facility failed to ensure a safe and sanitary environment for the residents. This affected three residents (#2, #7 and #39) of 28 residents reviewed during the initial pool.

Inspectors wroteBased on menu review, observation, interview, and policy review, the facility failed to ensure food was prepared in a form designed to meet individual needs when the prepared pureed food items were not the proper consistency. This affected five residents (#13, #5, #37, #54, #58) of five residents reviewed for ordered pureed diets. The census was 68.

Inspectors wroteBased on medical record review, review of facility investigation, policy review, and interview the facility failed to report an injury of unknown origin to the state survey agency. This affected one resident (#10) of three residents reviewed for accidents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's quarterly Minimum Data Set (MDS) assessment was completed accurately to reflect all known active medical diagnoses. This affected one resident (#3) of 20 residents reviewed for assessments.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARR) were complete and failed to ensure PASARR recommendations were implemented. This affected two residents (#9, #10) of two residents reviewed for accuracy of PASARR. The census was 68.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a comprehensive care plan was developed to address constipation for a resident receiving a stool softener on a scheduled basis. This affected one resident (#3) of 20 residents reviewed for care plans.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a resident's quarterly care planning conference was scheduled and the resident and/ or their family was afforded the opportunity to participate in their care planning process. This affected one resident (#7) of one resident reviewed for care planning conferences.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident, who was dependent on staff for personal care, received the assistance needed with receiving showers as scheduled. This affected one resident (#78) of four residents reviewed for activities of daily living.

Inspectors wroteBased on medical record review, observation, interview, and policy review the facility failed to timely and comprehensively assess a pressure ulcer. This affected one resident (#76) of two residents reviewed for pressure ulcers.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure a comprehensive assessment was completed to determine the type of urinary incontinence and failed to implement an effective treatment plan to address the resident's incontinence. This affected one resident (#54) of two residents reviewed for bowel and bladder incontinence. The census was 68.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure a resident's meal intakes were monitored and the resident was comprehensively assessed regarding weight loss. This affected one resident (#54) of four residents reviewed for nutrition. The census was 68.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to ensure a resident's dialysis port was assessed and monitored. This affected one resident (#76) of one resident reviewed for dialysis.

Inspectors wroteBased on record review, interview, observation, and policy review, the facility failed to properly store and administer medications. This affected two residents (#42, #22) of eight residents observed in the initial pool. The census was 68.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure residents didn't receive unnecessary antibiotic treatment. This affected two residents (#6 and #36) of three residents reviewed for urinary tract infections (UTI).

Inspectors wroteBased on record review, interviews, and policy reviews the facility failed to ensure COVID immunization consent forms were dated and failed to have documented evidence of education provided to residents and/ or representative of the risks and benefits of the COVID immunization. This affected one resident (#53) of five residents reviewed for immunizations. The census was 68.

Inspectors wroteBased on observations, medical record reviews, policy reviews, and staff interviews, the facility failed to implement appropriate infection control procedures for catheter care, wound care, and medication administration. This affected two (Residents #2 and #55) of seven residents observed during medication administration, one (Resident #67) of one resident observed for wound care, and one (Resident #25) of one resident observed for catheter care.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure staff were monitoring a resident's blood pressures prior to administration of medications which had the potential to lower the resident's blood pressure. This affected one (Resident #18) of six residents observed for medication administration.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure fall interventions were implemented for a resident at a high risk for falls. This affected one (Resident #64) of three residents reviewed for falls.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure the resident's medical record was complete and accurate. This affected one (Resident #103) of 13 residents reviewed for medical record accuracy.

Inspectors wroteBased on record review, staff interview, review of the infection control log, review of guidance from National Library of Medicine, and facility policy review, the facility failed to implement their antibiotic stewardship program to promote the appropriate use of antibiotics. This affected two (Residents #2 and #24) of three residents reviewed for antibiotic use. The facility census was 67.

Inspectors wroteBased on observations, staff interviews, policy review, and record review, the facility failed to maintain a call light system that was readily accessible to its residents. This affected two (Residents #19 and #30) of three residents reviewed for call light accessibility. The facility census was 67.

Inspectors wroteBased on medical record review, observation, staff interview and review of policy and procedure, the facility failed to maintain proper infection control procedures during incontinence care. This effected one (Resident #63) of six residents reviewed for urinary tract infections. The census was 72.

Inspectors wroteBased on interview, and record review the facility failed to ensure physician notification occurred related to elevated blood glucose levels resulting in the potential for inadequate diabetes management. This affected one resident (Resident #39) of five residents reviewed for medication management.

Inspectors wroteBased on observation, review of physician orders, review of drug manufacturer information, and interview, the facility failed to ensure medications were administered in accordance with physician orders and drug manufacturer directions. Four errors were identified out of 37 opportunities for error, resulting in a 10.8% medication error rate. This affected two (Residents #30 and #51) of five residents observed having medications administered by staff.

Inspectors wroteBased on medical record review, review of consultant reports, review of hospital records, and interview, the facility failed to write/transcribe orders resulting in a resident receiving ongoing treatment with an anti-neoplastic medication beyond ordered duration. This affected one (Resident #69) of three residents reviewed for medication use.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to ensure medication administration records were maintained in an accurate and complete manner for one (Resident #63) of three residents reviewed for medication administration.

Inspectors wroteBased on resident interview, staff interview, Computer Aided Dispatch (CAD) call report review, Self-Reported Incident (SRI) review, and medical record review, the facility failed to ensure Resident #72 received timely care and services which resulted in the resident reaching out to an outside entity for assistance. This affected one (Resident #72) out of three residents reviewed for quality of care and treatment. The facility census was 71.

Inspectors wroteBased on review of Controlled Medication Shift Change Log, controlled medication signature sheets, record review, review of the staff schedule, policy review, and interview, the facility failed to prevent misappropriation of resident medications. This had the potential to affect 11 residents (#7, #8, #11, #16, #17, #23, #25, #26, #28, #29 and #71) who received narcotic medication and resided on the 200 hall. The facility census was 70.

Inspectors wroteBased on medical record review, review of facility policy, and staff interview the facility failed to ensure accurate reconciliation of controlled medications. This affected 33 residents (#2, #3, #5, #6, #7, #8, #10, #11, #16, #17, #20, #22, #23, #24, #25, #26, #28, #29, #37, #43, #44, #46, #48, #49, #51, #53, #59, #60, #61, #62, #65, #66 and #67) who were ordered controlled medications. The facility census was 70.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure care and treatment was completed of diabetic foot ulcers. This affected one resident (#8) of three residents reviewed for skin impairment. The facility census was 70.

Inspectors wroteBased on record review, observation, policy review, and interview, the facility failed to ensure care and treatment of pressure ulcers was completed and consistent with professional standards of practice to promote healing, This affected one resident (#32) of three residents reviewed for skin impairment. The facility census was 70.

Inspectors wroteBased on record review and interview, the facility failed to ensure adequate monitoring with the administration of narcotic pain medication. This affected two residents (#8 and #26) of four residents reviewed for narcotics. The census was 70.

Inspectors wroteBased on review of controlled medication reconciliation records, observation, medical record review, and interview, the facility failed to ensure a narcotic medication was labeled to meet professional standards. This affected two residents (Resident #26 and #62) of 33 residents with controlled medications. The facility census was 70.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure accurate medical records. This affected two residents (#16, #71) of nine residents reviewed. The facility census was 70.

Inspectors wroteBased on record review, observation, policy review, and interview, the facility failed to ensure infection control measures were followed as ordered during a dressing change. This affected one resident (#32) of three residents reviewed for skin impairment. The facility census was 70.

Inspectors wroteBased on interviews and completion of a test tray the facility did not ensure food was served at palatable temperatures. This had the potential to affect all 59 residents who ate food prepared in the kitchen.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure dishes and eating utensils were sanitized appropriately when the high temperature dish machine was not meeting the hot water temperature required for sanitization. This had the potential to affect all 59 residents who used dishes and cutlery from the kitchen.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure facial protection was available in areas where staff would spray soiled linens, failed to ensure the facility's water management program for legionella prevention was implemented, and failed to utilize the most current tuberculosis rates when reviewing their tuberculosis risk assessment. This had the potential to affect all 76 residents.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure all medications were secured in an appropriate manner and discarded when expired. This affected three residents (Residents #21, #36 and #37) but had the potential to affect all 25 residents residing on the 200 unit. The facility census was 76.

Inspectors wroteBased on interview and record review, the facility failed to ensure Residents #227 and #228's personal funds were forwarded to the residents' estate within 30 days. This affected two (Residents #227 and #228) of two residents reviewed for personal funds after death. The facility census was 76.

Inspectors wroteBased on medical record review, policy review, and interview, the facility failed to ensure a resident's wish for receipt of cardiopulmonary resuscitation (CPR) was clearly established in the medical record. This affected one (Resident #128) of 24 residents reviewed for code status.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure comprehensive care plans were established. This affected two Residents (#14 and #54) of 18 residents reviewed for care plans. The facility census was 76.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #43 and #55's care plans were revised to reflect all fall interventions. This affected two (Residents #43 and #55) of three residents reviewed for falls. The facility census was 76.

Inspectors wroteBased on observations, medical record review, review of the facility's activity calendar, and interview, the facility failed to ensure an individualized activity program was provided and group activities were scheduled to permit participation by one (Resident #121) of two residents reviewed for activities.

Inspectors wroteBased on medical record review, interview, and policy review, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of an anti-anxiety medication ordered on an as necessary basis. This affected one (Resident #130) of five residents reviewed for medication use.

Inspectors wroteBased on medical record review and interview, the facility failed to offer pneumococcal vaccinations in accordance with recommended vaccination schedules from the Centers for Disease Control (CDC). This affected two (Residents #130 and #226) of five residents reviewed for immunizations.

Inspectors wroteBased on observations and interview, the facility failed to ensure the environment was maintained in a safe and sanitary manner. This had the potential to affect all residents on 100 hall (Residents #1, #2, #3, #4, #5, #6, #7, and #8) and one (Resident #41) of three residents observed for incontinence care. The facility census was 69.

Inspectors wroteBased on observations, medical record review, review of fall investigations, and interviews, the facility failed to implement fall interventions for three (Residents #45, #46, and #56) of five residents reviewed for falls. The facility census was 69.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to store nebulizer equipment in a sanitary manner for one (Resident #51) of three residents reviewed for use of nebulizer equipment. The facility census was 69.

Inspectors wroteBased on observation, review of the medical record, interview with staff and review of facility policy the facility failed to ensure Resident # 24, #32 and #68 received their physician ordered adaptive equipment for meals. This affected three residents (Resident #24, #32 and #68) of five residents reviewed for nutrition. The facility census was 71.

Inspectors wroteBased on observation, record review and interviews the facility did not ensure Resident #17, #40 and #48 had safe and appropriate transportation services provided to them to get to their dialysis treatments at a dialysis center outside of the facility. This affected three residents (#17, #40, and #48) of four reviewed for transportation to dialysis. The facility identified four residents (#17, #24, #40 and #48) who required transportation to dialysis. The facility census was 71.

Inspectors wroteBased on interview, observation, and air temperature, the facility failed to ensure the 300 hall central shower room was a comfortable temperature. This affected 17 residents (Residents #2, #7, #12, #16, #25, #28, #33, #36, #39, #46, #49, #51, #53, #57, #59, #63 and #317) on the 300 hall who utilized the shower. The facility census was 63.

Inspectors wroteBased on observations, review of the medical record, interviews with staff and facility policy review, the facility failed to ensure aerosol nebulizer masks were properly stored in a protective barrier for Residents #15, #49, #167, #168, and #169 and did not ensure the humidifier bottle was filled and oxygen orders were obtained for Resident #49. This affected five residents (Residents #15 #49, #167, #168, and #169) of five reviewed for respiratory therapy.

Inspectors wroteBased on record review and interview, the facility failed to develop comprehensive care plans in the areas of activities and activity of daily living. This affected two residents (Residents #12 and #217) of 17 residents reviewed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents received the assistance required to keep their fingernails clean and trimmed. This affected two (Residents #2 and #217) of three residents reviewed for activities of daily living.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure pressure reducing orders were written timely for Resident #8, dressing changes were completed and/or documented as completed for Residents #8, and #12, pressure reducing devices were in place as ordered for Residents #53 and a pressure ulcer dressing was applied after a shower, and ensure Resident #12's air mattress was supported to ensure his feet were not in a dependent position. This affected three (Residents #8, #12 and #53) of five residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure orders where in place for Resident #47's dialysis treatments and ensure the dialysis access site was assessed. This affected one out of one resident reviewed for dialysis. The facility identified two residents who received dialysis (Residents #47 and #49). The facility census was 63.

Inspectors wroteBased on interview, record review and pharmacy recommendation review the facility did not ensure pharmacy recommendations were addressed timely for Residents #2 and #47. This affected two of five residents reviewed for unnecessary medications (Resident #2, Resident #7, Resident #1, Resident #15, Resident #26). The facility census was 63.

Inspectors wroteBased on observation and interview, the facility failed to blend pureed food to a smooth consistency. This affected one (Resident #8) of one resident on a pureed diet. The facility census was 63.