Newcare

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not develop and/or implement an individualized, comprehensive care plan for 4 residents (R) (R11, R16, R6, and R13) of 14 sampled residents. R11 smoked and received oxygen therapy. R11 also received diuretic medication and was on contact and droplet precautions. The facility did not develop a comprehensive care plan that included interventions related to smoking, the use of diuretic medication, or infection prevention precautions. R16 smoked and received oxygen therapy. The facility did not develop a comprehensive care plan that included interventions related to smoking. R6's activities of daily living (ADL) and nutritional care plans did not include recommended approaches for staff to use when R6 refused to eat meals in a Broda chair or the dining room. R13 had an order for a WanderGuard for safety. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 17 residents (R) residing in the facility. R11 was not initially placed on precautions when R11 developed signs and symptoms of a respiratory infection, including a fever, increased cough, and increased wheezing, and was not included on the facility's respiratory surveillance line list. In addition, staff did not follow transmission-based precautions while caring for R11. R13 tested positive for influenza A on 8/6/25. R13's symptoms resolved date was not included on the facility's respiratory surveillance line list. R29 tested positive for influenza A on 8/4/25. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident (R) (R1) of 4 sampled residents. On 5/23/25, staff witnessed R2 strike R1 in the chest with an open hand multiple times. The facility did not report the incidence of abuse to local law enforcement.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 4 sampled residents. On 5/23/25, staff witnessed R2 strike R1 in the chest multiple times. Following the altercation, staff were not provided education to prevent further abuse among residents.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 4 residents (R) (R11, R16, R21, and R22) of 5 sampled residents. The facility did not offer R11, R16, R21, and R22 the Prevanr20® (PCV20) vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not report an allegation of sexual abuse to the State Agency (SA) for 2 residents (R) (R29 and R94) of 2 sampled residents. On 3/21/24, staff observed R29 seek out R94 after redirection and kiss R94 on the lips. The facility did not report the allegation of sexual abuse to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of sexual abuse was investigated for 2 residents (R) (R29 and R94) of 2 sampled residents. The facility did not investigate an allegation of sexual abuse involving R29 and R94.

Inspectors wrote2. On 6/18/24, Surveyor reviewed R29's medical record. R29 had diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, and adjustment disorder with mixed disturbance of emotions and conduct. R29's most recent MDS assessment, dated 4/10/24, documented a BIMS score of 1 out of 15 which indicated R29 had severe cognitive impairment. R29 had an activated Power of Attorney (POA) for medical decisions. A behavior care plan, initiated on 7/21/22 and updated on 3/19/24, stated R29 will not exhibit socially inappropriate/disruptive behavior through the next review period and indicated: R29 will often greet other residents by touching or rubbing their arm or leg in a friendly manner. R29 has become more affectionate toward male residents with no regard for personal privacy. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 2 residents (R) (R1 and R21) of 2 sampled residents. R1 and R21 resided in the same room. Signs posted outside R1 and R21's room indicated droplet precautions, airborne precautions, and contact precautions were in place. On 6/19/24, staff did not don the appropriate personal protective equipment (PPE) prior to entering R1 and R21's room to complete cares.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the accurate administration of medication for 1 Resident (R) (R1) of 8 sampled residents. R1's medical record contained a physician's order to administer furosemide (used to remove excess fluid from the body) as needed based on R1's weight changes. The facility did not administer the medication as ordered by R1's physician.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R28) of 1 resident received adequate supervision to prevent elopement. R28 was admitted to the facility on [DATE] and assessed to be at risk for elopement. R28 had diagnoses of schizophrenia and mild cognitive impairment. R28 wore a wanderguard, but was allowed to sit outside the front of the building while supervised by staff inside the building. On 10/10/22, R28 was observed by a Dietary Manager still on facility grounds, but beyond the adjacent Assisted Living facility. On 11/2/22, R28 was observed walking down the driveway toward the road. On 11/7/22, R28 was found at an apartment complex three blocks from the facility. The facility was unaware R28 eloped until contacted by the police. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 41 residents residing in the facility. The facility did not monitor and document dishwashing wash cycle temperatures. Staff did not test Quaternary sanitizing solution per manufacturer's instructions. Cook (CK)-E did not wash hands after performing tasks that contaminated CK-E's hands. Food cooking appliances (ovens, toaster, steam table) and kitchen food prep areas were not cleaned and sanitized.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R28) of 1 resident who had a Guardian received services to ensure a court-ordered protective placement was obtained. R28 was under Guardianship. The facility did not ensure R28 had a court-order to be protectively placed at the facility.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a resident suspected of having a mental illness and/or intellectual/developmental disability was screened through the Pre-admission Screen and Resident Review (PASRR) Level 2 process to determine if nursing home placement was appropriate and if specialized services were required for 1 Resident (R) (R28) of 12 sampled residents. The facility did not complete a PASRR Level 2 screen upon R28's admission to the facility or follow-up after a PASRR Level 2 was submitted when Zoloft (anti-depressant medication) was added to R28's medication regimen.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a complete baseline care plan was developed within 48 hours of admission for 1 Resident (R) (R92) of 1 sampled resident reviewed for new admission. R92 was admitted to the facility on [DATE] with orders to receive four different high-risk medications. R92's baseline care plan did not address the use of the high-risk medications.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide necessary respiratory care and services for 1 Resident (R) (R24) of 1 sampled resident. The facility did not clean R24's continuous positive airway pressure (CPAP) machine per manufacturer's instructions.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 37 opportunities which resulted in an 5.41% medication error rate affecting 2 Residents (R) (R23 and R34) of 4 residents observed during medication pass. R23 had a physician order for Miralax (used to treat and prevent constipation). During an observation of medication administration, Registered Nurse (RN)-C administered a partial dose of Miralax to R23 and left R23 with the remaining medication. R23 was not assessed to safely self-administer medication and did not receive the complete dose. In addition, R23's physician order for Miralax included the instruction to mix in eight ounces of water. RN-C mixed R23's Miralax in approximately five ounces of water. [...]